Basic Information
| Provider Information | |||||||||
| NPI: | 1457675068 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEVELAND | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7703 FLOYD CURL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104509000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 618 LIVE OAK | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782021932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102232944 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP109719 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0200X | AP109719 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 376046402 | 01 | TX | CSHCN | OTHER | 376046401 | 05 | TX | MEDICAID |