Provider Demographics
NPI:1083902027
Name:OLSON-GUGERTY, LISA A (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:OLSON-GUGERTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 COPELAND AVE
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-1528
Mailing Address - Country:US
Mailing Address - Phone:607-749-2640
Mailing Address - Fax:607-749-2644
Practice Address - Street 1:82 COPELAND AVE
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:NY
Practice Address - Zip Code:13077-1528
Practice Address - Country:US
Practice Address - Phone:607-749-2640
Practice Address - Fax:607-749-2644
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336857363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03411983Medicaid
NYJ400063066Medicare PIN