Healthcare Provider Details

I. General information

NPI: 1811928039
Provider Name (Legal Business Name): LISA MARIE WALTER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E HERNDON AVE
FRESNO CA
93720-3235
US

IV. Provider business mailing address

1207 E HERNDON AVE
FRESNO CA
93720-3235
US

V. Phone/Fax

Practice location:
  • Phone: 559-432-4303
  • Fax: 559-432-4574
Mailing address:
  • Phone: 559-432-4303
  • Fax: 559-432-4574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12689
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number352673
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: