Provider Demographics
NPI:1003903915
Name:LISS, PAUL L (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:L
Last Name:LISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8510 E BUES POINT RD
Mailing Address - Street 2:
Mailing Address - City:BAILEYS HARBOR
Mailing Address - State:WI
Mailing Address - Zip Code:54202-9624
Mailing Address - Country:US
Mailing Address - Phone:920-839-2630
Mailing Address - Fax:
Practice Address - Street 1:8510 E BUES POINT RD
Practice Address - Street 2:
Practice Address - City:BAILEYS HARBOR
Practice Address - State:WI
Practice Address - Zip Code:54202-9624
Practice Address - Country:US
Practice Address - Phone:920-839-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30266700Medicaid
WI015272200Medicare ID - Type Unspecified
WIB54620Medicare UPIN