Basic Information
| Provider Information | |||||||||
| NPI: | 1285656603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMONS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 E US HWY 290 | ||||||||
| Address2: | STE. 420 - CREDENTIALING | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787231098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123383826 | ||||||||
| FaxNumber: | 5124066216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1807 W SLAUGHTER LN STE 490 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122828967 | ||||||||
| FaxNumber: | 5124067351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K2876 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104502303 | 05 | TX | MEDICAID | 104502307 | 05 | TX | MEDICAID | 104502308 | 05 | TX | MEDICAID |