Healthcare Provider Details

I. General information

NPI: 1023101920
Provider Name (Legal Business Name): LISA M HARRISON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MARIE EDWARDS O.D.

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 JACKIE RD SE
RIO RANCHO NM
87124-6610
US

IV. Provider business mailing address

4025 JACKIE RD SE
RIO RANCHO NM
87124-6610
US

V. Phone/Fax

Practice location:
  • Phone: 714-449-7428
  • Fax: 505-375-4793
Mailing address:
  • Phone: 714-449-7428
  • Fax: 505-375-4793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number621
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13010TPA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: