Provider Demographics
NPI:1629619531
Name:KOGAN, LISA (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KOGAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W TELEGRAPH ST UNIT 242
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-6009
Mailing Address - Country:US
Mailing Address - Phone:435-229-4473
Mailing Address - Fax:435-236-6300
Practice Address - Street 1:47 N 100 E
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3402
Practice Address - Country:US
Practice Address - Phone:435-229-4473
Practice Address - Fax:435-236-6300
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5992251-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner