Healthcare Provider Details

I. General information

NPI: 1245646629
Provider Name (Legal Business Name): LISA MARIE BLASKO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE MARTIN DNP,FNP-C

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E MAIN ST STE B
PAYSON AZ
85541-5618
US

IV. Provider business mailing address

113 E BROWN RD
STAR VALLEY AZ
85541-6561
US

V. Phone/Fax

Practice location:
  • Phone: 928-472-2225
  • Fax: 928-468-0002
Mailing address:
  • Phone: 928-472-2225
  • Fax: 928-468-0002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberTAP5705
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN152442
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: