Provider Demographics
NPI:1235257346
Name:WHITTAKER, LISA M (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-266-8822
Mailing Address - Fax:970-266-8833
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:SUITE 230
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-266-8822
Practice Address - Fax:970-266-8833
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003260363A00000X
PAMA-002706-L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY133400000Medicaid
CO15228576Medicaid
COP01142121OtherMEDICARE RAILROAD
WY133400000Medicaid