Provider Demographics
NPI:1699874081
Name:FARGO, LISA A (LMT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:FARGO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13165 SW ESSEX DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5646
Mailing Address - Country:US
Mailing Address - Phone:971-645-2257
Mailing Address - Fax:
Practice Address - Street 1:3800 SW CEDAR HILLS BLVD
Practice Address - Street 2:#203
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2027
Practice Address - Country:US
Practice Address - Phone:971-645-2257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11230174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist