Provider Demographics
NPI:1114919727
Name:KISTNER, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KISTNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 PEACE HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4817
Mailing Address - Country:US
Mailing Address - Phone:336-713-7800
Mailing Address - Fax:336-713-7802
Practice Address - Street 1:1930 PEACE HAVEN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4817
Practice Address - Country:US
Practice Address - Phone:336-713-7800
Practice Address - Fax:336-713-7802
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-00695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913695Medicaid
E16361Medicare UPIN