Provider Demographics
NPI:1770937682
Name:SYTSMA, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SYTSMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:IA
Mailing Address - Zip Code:50054-1039
Mailing Address - Country:US
Mailing Address - Phone:515-674-9020
Mailing Address - Fax:515-674-9155
Practice Address - Street 1:107 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:IA
Practice Address - Zip Code:50054-1039
Practice Address - Country:US
Practice Address - Phone:515-674-9020
Practice Address - Fax:515-674-9155
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-17
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA133377363L00000X, 364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1902269632Medicare PIN