Provider Demographics
NPI:1740214642
Name:WHITTOM, LISA (ARNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WHITTOM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W 13TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-3650
Mailing Address - Country:US
Mailing Address - Phone:785-621-4990
Mailing Address - Fax:785-628-8719
Practice Address - Street 1:105 W 13TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-3650
Practice Address - Country:US
Practice Address - Phone:785-621-4990
Practice Address - Fax:785-628-8719
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45873363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS161702Medicare ID - Type UnspecifiedMEDICARE
KSQ70704Medicare UPIN