Provider Demographics
NPI:1588319438
Name:BRUNER, LISA JO (ARDMS)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:JO
Last Name:BRUNER
Suffix:
Gender:F
Credentials:ARDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2487 N ARTURO CIR W
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-7955
Mailing Address - Country:US
Mailing Address - Phone:928-800-1640
Mailing Address - Fax:
Practice Address - Street 1:2487 N ARTURO CIR W
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7955
Practice Address - Country:US
Practice Address - Phone:928-800-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1911372085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty