Provider Demographics
NPI:1104214956
Name:IRWIN, LISA (CST, CSFA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:IRWIN
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11456 WAR ADMIRAL DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4423
Mailing Address - Country:US
Mailing Address - Phone:317-446-6692
Mailing Address - Fax:
Practice Address - Street 1:395 WESTFIELD RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1425
Practice Address - Country:US
Practice Address - Phone:317-770-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN156457246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant