Provider Demographics
NPI:1245646629
Name:BLASKO, LISA MARIE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:BLASKO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9879
Mailing Address - Fax:
Practice Address - Street 1:126 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5488
Practice Address - Country:US
Practice Address - Phone:928-468-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN152442163WM0705X
AZTAP5705363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical