Basic Information
Provider Information | |||||||||
NPI: | 1508491176 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FALLON | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MASSEY | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP-BC | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1335 GERONIMO DR STE 8 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799251836 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155912704 | ||||||||
FaxNumber: | 9155983946 | ||||||||
Practice Location | |||||||||
Address1: | 6974 GATEWAY BLVD E STE F | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799151115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155912704 | ||||||||
FaxNumber: | 9155983946 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2020 | ||||||||
LastUpdateDate: | 03/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | API44027 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.