Provider Demographics
NPI:1912439381
Name:HAIRSTON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HAIRSTON
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 1:2760 W PEORIA AVE STE 1242
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5202
Mailing Address - Country:US
Mailing Address - Phone:562-684-7575
Mailing Address - Fax:
Practice Address - Street 1:9705 E MOUNTAIN VIEW RD STE 220
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5235
Practice Address - Country:US
Practice Address - Phone:562-684-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017383363LF0000X
AZ292113363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily