Healthcare Provider Details

I. General information

NPI: 1700495207
Provider Name (Legal Business Name): LISA RENAE BIGELOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 SPANISH TRAIL, P132
EAGAR AZ
85925-8592
US

IV. Provider business mailing address

606 N MAIN ST
EAGAR AZ
85925-9813
US

V. Phone/Fax

Practice location:
  • Phone: 928-245-0012
  • Fax:
Mailing address:
  • Phone: 928-333-5333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number242067
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: