Provider Demographics
NPI:1366737157
Name:MOORE-BRANDON, LISA DIANE (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:MOORE-BRANDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DIANE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4502 N 2ND DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2912
Mailing Address - Country:US
Mailing Address - Phone:480-529-7213
Mailing Address - Fax:
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:480-529-7213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0675207P00000X
AZ006369207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine