Basic Information
| Provider Information | |||||||||
| NPI: | 1568942571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104509000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103582078 | ||||||||
| FaxNumber: | 2103581972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2018 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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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 | 363L00000X | AP138521 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP138521 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 388606102 | 01 | TX | CSHCN | OTHER | 388606101 | 05 | TX | MEDICAID |