Provider Demographics
NPI:1093756587
Name:BURTON, LISA K (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:BURTON
Suffix:
Gender:F
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:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-773-8012
Mailing Address - Fax:307-633-7676
Practice Address - Street 1:5201 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4741
Practice Address - Country:US
Practice Address - Phone:307-632-1114
Practice Address - Fax:307-632-9920
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35214208600000X
WY8731A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01352145Medicaid
CO01352145Medicaid
COR5888Medicare PIN
COCO40976Medicare PIN
COCO303606Medicare PIN