1003091430 NPI number — MRS. LISA ANN RUNYON CPNP

Table of content: MRS. LISA ANN RUNYON CPNP (NPI 1003091430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003091430 NPI number — MRS. LISA ANN RUNYON CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUNYON
Provider First Name:
LISA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003091430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N MEDICAL DR
Provider Second Line Business Mailing Address:
TRAUMA SERVICES
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84113-1103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-662-2993
Provider Business Mailing Address Fax Number:
801-662-2999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N MEDICAL DR
Provider Second Line Business Practice Location Address:
TRAUMA SERVICES
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84113-1103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-662-2993
Provider Business Practice Location Address Fax Number:
801-662-2999
Provider Enumeration Date:
01/03/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  216679-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)