Basic Information
| Provider Information | |||||||||
| NPI: | 1568518728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | URI | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | JILL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977090670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413897741 | ||||||||
| FaxNumber: | 5412788375 | ||||||||
| Practice Location | |||||||||
| Address1: | 2175 NW SHEVLIN PARK RD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977037101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413897741 | ||||||||
| FaxNumber: | 5412788375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2007 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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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 | 207Q00000X | MD26780 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 271144 | 05 | OR | MEDICAID |