Individual
LISA DEPTULA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA, MD
Contact information
Practice address
7601 SOUTHCREST PKWY, SOUTHAVEN, MS 38671-4739
(662) 772-3607
Mailing address
7601 SOUTHCREST PKWY, SOUTHAVEN, MS 38671-4739
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
5601006710
MI
363A00000X
Physician Assistant
PA54017
CA
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
10/22/2013
Last updated
04/22/2025
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