Healthcare Provider Details

I. General information

NPI: 1962640920
Provider Name (Legal Business Name): LISA K TAYLOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 12/21/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N 2ND ST SUITE 215
BOISE ID
83702-6109
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7340
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA106188
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberM-12566
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: