Basic Information
| Provider Information | |||||||||
| NPI: | 1053670968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREITERMAN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 N CENTRAL AVE STE 1001 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024064786 | ||||||||
| FaxNumber: | 9166364358 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W THOMAS RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024069999 | ||||||||
| FaxNumber: | 6024068099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 094553 | AZ | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP4605 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | AP4605 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP0808X | AP11187 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 733126 | 05 | AZ | MEDICAID |