Provider Demographics
NPI:1083679989
Name:ANDERSON, LISA M (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:10433 S REDWOOD RD STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8502
Mailing Address - Country:US
Mailing Address - Phone:801-260-1919
Mailing Address - Fax:801-260-1441
Practice Address - Street 1:1126 E 12300 S
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9095
Practice Address - Country:US
Practice Address - Phone:801-545-0500
Practice Address - Fax:801-545-0626
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT4842000-1205207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G91692Medicare UPIN
UT005534711Medicare PIN