Provider Demographics
NPI:1073682993
Name:PETERSON, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:SANDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4701 NORMAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-5563
Mailing Address - Country:US
Mailing Address - Phone:402-488-5050
Mailing Address - Fax:402-488-5001
Practice Address - Street 1:4701 NORMAL BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-5563
Practice Address - Country:US
Practice Address - Phone:402-488-5050
Practice Address - Fax:402-488-5001
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100263068-00Medicaid
NE274306Medicare ID - Type Unspecified
NE100263068-00Medicaid