=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225296239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LISA L SWANSON MD DBA MESQUITE PEDIATRIC ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2008
-----------------------------------------------------
Last Update Date | 05/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3220 GUS THOMASSON RD STE 350
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-613-3883
-----------------------------------------------------
Fax | 972-686-7981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3220 GUS THOMASSON RD STE 350
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-613-3883
-----------------------------------------------------
Fax | 972-686-7981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LISA LOUISE SWANSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-613-3883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | H0867
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------