Provider Demographics
NPI:1144548603
Name:DEBOER, LISA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:DEBOER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12221 N MOPAC EXPY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2401
Mailing Address - Country:US
Mailing Address - Phone:512-901-4937
Mailing Address - Fax:
Practice Address - Street 1:1330 WONDER WORLD DR
Practice Address - Street 2:SUITE #101
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7566
Practice Address - Country:US
Practice Address - Phone:512-805-0680
Practice Address - Fax:512-805-0682
Is Sole Proprietor?:No
Enumeration Date:2010-05-08
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX794741363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB163669Medicare PIN