Basic Information
| Provider Information | |||||||||
| NPI: | 1013148980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUBBARD | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10625 W NORTH AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148775350 | ||||||||
| FaxNumber: | 4148775360 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 W CHAMBERS ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532101650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144472000 | ||||||||
| FaxNumber: | 4148744393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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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 | 207P00000X | 122075-30 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363L00000X | 122075-30 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3835-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1013148980 | 01 | WI | BLUE CROSS BLUE SHIELD | OTHER |