Lisa Deptula, PA, MD

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

Practice address

7601 Southcrest Pkwy
Southaven, MS 38671-4739

Phone

(662) 772-3607

NPI assigned

Oct 22, 2013

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Jan 1, 2019 through Jan 1, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine, Physician Assistant

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1382400000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1745280000000",
    "number": "1184052508",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7601 SOUTHCREST PKWY",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386714739"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7601 SOUTHCREST PKWY",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386714739",
            "telephone_number": "662-772-3607"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2144 4th St Ste A",
            "address_purpose": "LOCATION",
            "city": "San Rafael",
            "state": "CA",
            "postal_code": "94901",
            "country_code": "US",
            "telephone_number": "415-390-2060",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "203 Winston Dr",
            "address_purpose": "LOCATION",
            "city": "Marshall",
            "state": "MI",
            "postal_code": "490688526",
            "country_code": "US",
            "telephone_number": "269-789-1670",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DEPTULA",
        "first_name": "LISA",
        "credential": "PA, MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2013-10-22",
        "last_updated": "2025-04-22",
        "certification_date": "2025-04-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "PA54017",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MI",
            "license": "5601006710",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Student in an Organized Health Care Education/Training Program in Southaven, MS
• Providers in Southaven, MS by specialty
• Student in an Organized Health Care Education/Training Program in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 22, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.