MEDICARE: LISA BYRD P.A.-C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	7973035-1206	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	031828	OTHER	AZ	MEDICARE
2	61788	OTHER	AZ	MEDICARE

General Provider Information

NPI Number	:	1962405522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BYRD P.A.-C.

Provider Business Mailing Address
First Line	:	1055 N 500 W
Second Line	:	ATTN: CREDENTIALING
City	:	PROVO
State	:	UT
Zip	:	84604-3305
Country	:	US
Telephone Number	:	801-354-8225
Fax Number	:	801-418-0941

Provider Business Practice Location Address
First Line	:	5896 S RIDGELINE DR
Second Line	:	SUITE B
City	:	OGDEN
State	:	UT
Zip	:	84405-6779
Country	:	US
Telephone Number	:	801-866-0170
Fax Number	:	801-866-0169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	11/27/2023

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