Basic Information
| Provider Information | |||||||||
| NPI: | 1104214956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRWIN | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | CST, CSFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11456 WAR ADMIRAL DR | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460604423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174466692 | ||||||||
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| Practice Location | |||||||||
| Address1: | 395 WESTFIELD RD | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460601425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177702800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2015 | ||||||||
| LastUpdateDate: | 01/02/2015 | ||||||||
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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 | 246ZC0007X | 156457 | IN | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.