Basic Information
| Provider Information | |||||||||
| NPI: | 1801072020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | LAVONN | ||||||||
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| Credential: | RN CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | DIVISION OF VASCULAR SURGERY, MMC 195 | ||||||||
| Address2: | 420 DELAWARE STREET SE MMC 195 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126264893 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 CAMPUS DR | ||||||||
| Address2: | SUITE 30 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633982203 | ||||||||
| FaxNumber: | 7633982233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2008 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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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 | 364SA2200X | R1414190 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
No ID Information.