Provider Demographics
NPI:1962405522
Name:BYRD, LISA (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BYRD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:5896 S RIDGELINE DR
Practice Address - Street 2:SUITE B
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6779
Practice Address - Country:US
Practice Address - Phone:801-866-0170
Practice Address - Fax:801-866-0169
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7973035-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ031828OtherMEDICARE
AZ61788OtherMEDICARE
84926Medicare PIN
Q26450Medicare UPIN