MEDICARE: LISY MONTANO BREA N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP131895	TX

General Provider Information

NPI Number	:	1124577564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISY MONTANO BREA N.P.

Provider Business Mailing Address
First Line	:	9495 MARSH LN
Second Line	:	SUITE100
City	:	DALLAS
State	:	TX
Zip	:	75220-4946
Country	:	US
Telephone Number	:	214-351-0010
Fax Number	:	214-351-0375

Provider Business Practice Location Address
First Line	:	9495 MARSH LN
Second Line	:	SUITE100
City	:	DALLAS
State	:	TX
Zip	:	75220-4946
Country	:	US
Telephone Number	:	214-351-0010
Fax Number	:	214-351-0375

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2016
Last Update Date	:	09/27/2016

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