Provider Demographics
NPI:1841433711
Name:GERACE, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GERACE
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 1:3877 N 7TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5061
Mailing Address - Country:US
Mailing Address - Phone:602-280-9629
Mailing Address - Fax:602-280-9644
Practice Address - Street 1:3877 N 7TH ST STE 400
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5061
Practice Address - Country:US
Practice Address - Phone:602-280-9629
Practice Address - Fax:602-280-9644
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN087146363LN0005X
AZAP1739363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z147265Medicare PIN