Basic Information
| Provider Information | |||||||||
| NPI: | 1003054305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOELLER | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2758 | ||||||||
| Address2: | 4150 KIMBALL AVE | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507042758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192355390 | ||||||||
| FaxNumber: | 3192355607 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 EAST DONALD STREET | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507031223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192361911 | ||||||||
| FaxNumber: | 3192875832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2009 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A114046 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1003054305 | 05 | IA | MEDICAID | 1003054305 | 01 | IA | WELLMARK BCBS | OTHER | P00704358 (PTAN) | 01 | IA | RR MEDICARE | OTHER | 421417307-UZ | 01 | IA | UHC/RIVER VALLEY/JD | OTHER |