1366535445 NPI number — DR. LISA J HERRIN MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366535445 NPI number — DR. LISA J HERRIN MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

HERRIN

Provider First Name:

LISA

Provider Middle Name:

J

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1366535445

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

04/14/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

14100 SAN PEDRO AVE STE 600

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SAN ANTONIO

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

78232-4363

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

210-981-1975

Provider Business Mailing Address Fax Number:

817-568-5474

Provider First Line Business Practice Location Address:

4200 SOUTH FWY STE 100

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

FORT WORTH

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

76115-1407

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

817-750-7334

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

10/02/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207PP0204X , with the licence number:  H4400 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X , with the licence number: H4400 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 1003887985 . This is a "GRP NPI NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 1729016 . This is a "FIRSTHEALTH PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 9057411 . This is a "PHCS PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 140442857 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 8M3077 . This is a "BCBSTX IND PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 132731409 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 132731411 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 6811699 . This is a "CIGNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 163314101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 4586688 . This is a "AETNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 0087LE . This is a "BCBSTX GRP PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".