Provider Demographics
NPI:1457758336
Name:ZIMMERER, LISA WEBER (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:WEBER
Last Name:ZIMMERER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 BLUEBONNET DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-1445
Mailing Address - Country:US
Mailing Address - Phone:214-908-8674
Mailing Address - Fax:
Practice Address - Street 1:7367 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-1883
Practice Address - Country:US
Practice Address - Phone:682-204-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant