Basic Information
| Provider Information | |||||||||
| NPI: | 1093756587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20970 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820037020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077738012 | ||||||||
| FaxNumber: | 3076337676 | ||||||||
| Practice Location | |||||||||
| Address1: | 5201 YELLOWSTONE RD | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820094741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076321114 | ||||||||
| FaxNumber: | 3076329920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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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 | 208600000X | 35214 | CO | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 8731A | WY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01352145 | 05 | CO | MEDICAID |