Provider Demographics
NPI:1790051274
Name:GRIMALDI, LISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRIMALDI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GRIMALDI-PAWAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:GRIMALDI-PAWAR
Mailing Address - Street 1:PO BOX 772886
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80477-2886
Mailing Address - Country:US
Mailing Address - Phone:970-879-0689
Mailing Address - Fax:
Practice Address - Street 1:3101 MENAUL BLVD NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1872
Practice Address - Country:US
Practice Address - Phone:505-842-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5134363A00000X
CO3371363A00000X
UT11578037-1206363A00000X
CA58871363A00000X
NMPA2013-0017363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical