Provider Demographics
NPI:1992014450
Name:WITHERSPOON, LISA DIANE (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-358-2078
Mailing Address - Fax:210-702-6274
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-2078
Practice Address - Fax:210-702-6274
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010161363LW0102X
IL309008440363LW0102X
TXAP115458363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health