Provider Demographics
NPI:1477606028
Name:DILLON, LISA (APN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:DILLON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DILLON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN
Mailing Address - Street 1:117 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-2309
Mailing Address - Country:US
Mailing Address - Phone:870-347-3314
Mailing Address - Fax:
Practice Address - Street 1:1127 MAIN ST
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173-9525
Practice Address - Country:US
Practice Address - Phone:501-796-6740
Practice Address - Fax:501-796-6744
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR30294363L00000X
ARA001170363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136660758Medicaid
AR136660758Medicaid
ARS69757Medicare UPIN
AR281830YJG2Medicare PIN