Healthcare Provider Details

I. General information

NPI: 1992797450
Provider Name (Legal Business Name): LISA MARIE YORK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6152 HARDSCRABBLE ROAD
PINE AZ
85544
US

IV. Provider business mailing address

PO BOX 409
PINE AZ
85544-0409
US

V. Phone/Fax

Practice location:
  • Phone: 928-476-3258
  • Fax: 928-476-3186
Mailing address:
  • Phone: 928-476-3258
  • Fax: 928-476-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24012
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: