Provider Demographics
NPI:1639796485
Name:EBERHARDT, LISA ANN (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:EBERHARDT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-783-3110
Mailing Address - Fax:
Practice Address - Street 1:101 JORDAN RD STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-8323
Practice Address - Country:US
Practice Address - Phone:518-274-9126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-28
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345936363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily