Healthcare Provider Details

I. General information

NPI: 1013112424
Provider Name (Legal Business Name): LISA I HARDISTY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PLEASANT ST
DES MOINES IA
50309-1406
US

IV. Provider business mailing address

1200 PLEASANT ST SOUTH 2 ROOM 236
DES MOINES IA
50309-1406
US

V. Phone/Fax

Practice location:
  • Phone: 515-241-5926
  • Fax: 515-241-5127
Mailing address:
  • Phone: 515-241-6228
  • Fax: 515-241-8685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25715
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR-8037
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41384
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: