Healthcare Provider Details

I. General information

NPI: 1528049178
Provider Name (Legal Business Name): LISA R RENDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3381 W BAVARIA ST
EAGLE ID
83616-5341
US

IV. Provider business mailing address

3381 W BAVARIA ST
EAGLE ID
83616-5341
US

V. Phone/Fax

Practice location:
  • Phone: 208-287-1110
  • Fax: 208-639-4801
Mailing address:
  • Phone: 208-287-1110
  • Fax: 208-639-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberM9105
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: