Provider Demographics
NPI:1225205941
Name:DITLEV ASTE, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:DITLEV ASTE
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:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84603-0270
Mailing Address - Country:US
Mailing Address - Phone:801-344-4411
Mailing Address - Fax:801-344-4225
Practice Address - Street 1:1300 E CENTER ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3554
Practice Address - Country:US
Practice Address - Phone:801-344-4411
Practice Address - Fax:801-344-4225
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180143 1205208D00000X
UT1801431205111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT09606Medicaid
UT09606Medicaid
UT006733011Medicare PIN