Basic Information
| Provider Information | |||||||||
| NPI: | 1164809729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNERS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARJORIE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 WELLNESS WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024322233 | ||||||||
| FaxNumber: | 7028005456 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 SHADOW LANE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023888436 | ||||||||
| FaxNumber: | 7023888431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2015 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | SL1072 | NV | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1164809729 | 05 | NV | MEDICAID |