Basic Information
Provider Information | |||||||||
NPI: | 1336131986 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETERSON | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 945 N 12TH ST | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532331305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4142197370 | ||||||||
FaxNumber: | 4142197967 | ||||||||
Practice Location | |||||||||
Address1: | 945 N 12TH ST | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532331305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4142197370 | ||||||||
FaxNumber: | 4142197967 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2005 | ||||||||
LastUpdateDate: | 07/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 03/21/2006 | ||||||||
NPIReactivationDate: | 04/10/2006 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 42769 | WI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RN0300X | 42769 | WI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RH0002X | 42769-21 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
ID | Type | State | Issuer | Description | 43548700 | 05 | WI |   | MEDICAID |