Basic Information
| Provider Information | |||||||||
| NPI: | 1760885198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3203 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LINDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757717727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038820991 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2014 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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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 | 363L00000X | AP126466 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | P01408022 | 01 | TX | RAILROAD MEDICARE | OTHER | 341244701 | 05 | TX | MEDICAID | 8759NL | 01 | TX | BCBS | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER |