Basic Information
| Provider Information | |||||||||
| NPI: | 1003342734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | MSN, AGNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7476 N CAMINO DE LA TIERRA | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857412123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204297166 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 504 W 29TH ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857133353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208385600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2017 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | AP10054 | AZ | N | Nursing Service Providers | Registered Nurse | General Practice | 363LG0600X | AP10054 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 276234 | 05 | AZ | MEDICAID |