Provider Demographics
NPI:1427222827
Name:STUBBS, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:STUBBS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1305
Mailing Address - Country:US
Mailing Address - Phone:801-373-2001
Mailing Address - Fax:801-373-4748
Practice Address - Street 1:1900 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1305
Practice Address - Country:US
Practice Address - Phone:801-373-2001
Practice Address - Fax:801-373-4748
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6291261-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant