Basic Information
| Provider Information | |||||||||
| NPI: | 1508976523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANTON | ||||||||
| FirstName: | LIZA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362405454 | ||||||||
| FaxNumber: | 6369805335 | ||||||||
| Practice Location | |||||||||
| Address1: | 2630 HIGHWAY K | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633686624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362405454 | ||||||||
| FaxNumber: | 6369805335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 05/18/2012 | ||||||||
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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 | 207Q00000X | 110103 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204963102 | 05 | MO | MEDICAID |