Healthcare Provider Details

I. General information

NPI: 1992226021
Provider Name (Legal Business Name): LISA NICOLE ANDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W STE 101
PROVO UT
84604-3381
US

IV. Provider business mailing address

3550 N UNIVERSITY AVE STE 250
PROVO UT
84604-6695
US

V. Phone/Fax

Practice location:
  • Phone: 801-852-3460
  • Fax: 801-852-3459
Mailing address:
  • Phone: 801-374-9625
  • Fax: 801-374-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number35.149055
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number664589
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberV2686
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number14242949-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: