Provider Demographics
NPI:1639126063
Name:CARPENTER, LISA JANE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JANE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 VIA DEL AQUA CV
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6761
Mailing Address - Country:US
Mailing Address - Phone:928-768-2426
Mailing Address - Fax:
Practice Address - Street 1:1611 JOY LN
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-8807
Practice Address - Country:US
Practice Address - Phone:928-788-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ1831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1831OtherSTATE LICENSE