Provider Demographics
NPI:1982710299
Name:KUNTZ, LISA LEDLOW (CRNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LEDLOW
Last Name:KUNTZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MEDICAL PARK DRIVE EAST
Mailing Address - Street 2:STE 307
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235
Mailing Address - Country:US
Mailing Address - Phone:205-838-3047
Mailing Address - Fax:205-838-3497
Practice Address - Street 1:52 MEDICAL PARK DRIVE EAST
Practice Address - Street 2:STE 307
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235
Practice Address - Country:US
Practice Address - Phone:205-838-3047
Practice Address - Fax:205-838-3497
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALKUNI04291580363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL63-0620636OtherTAX ID
AL051517707OtherBCBS OF ALABAMA
AL051552793Medicaid
AL1982710299OtherNPI
AL051500128OtherBCBS OF AL
AL051552793Medicaid
AL051517707OtherBCBS OF ALABAMA