Provider Demographics
NPI:1659340453
Name:FAIST, LISA ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELLEN
Last Name:FAIST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ELLEN
Other - Last Name:FAIST-STANTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3 RIVERSIDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016
Mailing Address - Country:US
Mailing Address - Phone:540-224-5170
Mailing Address - Fax:540-985-9612
Practice Address - Street 1:3 RIVERSIDE CIRCLE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-985-9612
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332601363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA7377Medicare ID - Type Unspecified
NYQ47388Medicare UPIN