Provider Demographics
NPI:1518313535
Name:DAN LISTER, MD PA
Entity Type:Organization
Organization Name:DAN LISTER, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:LISTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-250-2020
Mailing Address - Street 1:309 SOUTHRIDGE BLVD
Mailing Address - Street 2:STE. A
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-8875
Mailing Address - Country:US
Mailing Address - Phone:501-250-2020
Mailing Address - Fax:501-250-0200
Practice Address - Street 1:309 SOUTHRIDGE BLVD
Practice Address - Street 2:STE. A
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-8875
Practice Address - Country:US
Practice Address - Phone:501-250-2020
Practice Address - Fax:501-250-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1741208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134576001Medicaid
G74520Medicare UPIN
5K856Medicare PIN