Provider Demographics
NPI:1104848118
Name:LISTER, DONNA J (NP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:J
Last Name:LISTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-477-3317
Mailing Address - Fax:
Practice Address - Street 1:15 EAST 400 NORTH
Practice Address - Street 2:
Practice Address - City:PAROWAN
Practice Address - State:UT
Practice Address - Zip Code:84761
Practice Address - Country:US
Practice Address - Phone:435-477-3317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT962076824405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005779701Medicare PIN
UT000063385Medicare PIN