Provider Demographics
NPI:1285631044
Name:TABOR, LISA KATHERINE (APRN, ACNP-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KATHERINE
Last Name:TABOR
Suffix:
Gender:F
Credentials:APRN, ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9900 BREN ROAD EAST
Mailing Address - Street 2:MAIL ROUTE MN 008-8213
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343
Mailing Address - Country:US
Mailing Address - Phone:337-804-2049
Mailing Address - Fax:
Practice Address - Street 1:6545 S FORT APACHE RD STE 135-228
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-6752
Practice Address - Country:US
Practice Address - Phone:337-804-2049
Practice Address - Fax:877-866-3181
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVAPRN002065363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1477427Medicaid
LAQ39641Medicare UPIN
LA1477427Medicaid