Provider Demographics
NPI:1003986316
Name:COOK, LISA (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:W129N7055 NORTHFIELD DR
Mailing Address - Street 2:BLDG A, STE 203
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0538
Mailing Address - Country:US
Mailing Address - Phone:262-253-7155
Mailing Address - Fax:262-253-7140
Practice Address - Street 1:W129N7055 NORTHFIELD DR
Practice Address - Street 2:BLDG A, STE 203
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-0538
Practice Address - Country:US
Practice Address - Phone:262-253-7155
Practice Address - Fax:262-253-7140
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003986316Medicaid
WI1071974OtherNCCPA
WI736011553Medicare PIN