Basic Information
| Provider Information | |||||||||
| NPI: | 1366551137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 S ONEWOOD CIR | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670028851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163051160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 N HILLSIDE ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672144910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169628580 | ||||||||
| FaxNumber: | 3169628581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363LN0000X | 45799 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 200377070A | 05 | KS | MEDICAID | 161675 | 01 | KS | BCBS OF KANSAS | OTHER |