Provider Demographics
NPI:1689857062
Name:MUTO, LISA DAWN (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DAWN
Last Name:MUTO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HAL GREER BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4114
Mailing Address - Country:US
Mailing Address - Phone:304-399-6666
Mailing Address - Fax:304-399-6667
Practice Address - Street 1:1400 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-4114
Practice Address - Country:US
Practice Address - Phone:304-399-6666
Practice Address - Fax:304-399-6667
Is Sole Proprietor?:No
Enumeration Date:2007-12-09
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57366363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner