Provider Demographics
NPI:1366729279
Name:ECKHARDT, LISA DAWN (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DAWN
Last Name:ECKHARDT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-0280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5460 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-5525
Practice Address - Country:US
Practice Address - Phone:405-610-6998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-05
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001357A363AM0700X
MO2015007864363AM0700X
IL085004016363AM0700X
OK2550363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207465Medicare PIN