Provider Demographics
NPI:1184642662
Name:KOESTER-WIEDEMANN, LISA A (ANP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:KOESTER-WIEDEMANN
Suffix:
Gender:F
Credentials:ANP
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:MSC 8126-00021-08801
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-286-0801
Mailing Address - Fax:314-286-0855
Practice Address - Street 1:4205 FOREST PARK AVE
Practice Address - Street 2:DIV IM NEPHROLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2810
Practice Address - Country:US
Practice Address - Phone:314-286-0800
Practice Address - Fax:314-286-0855
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-09-21
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Provider Licenses
StateLicense IDTaxonomies
MO134512363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425146008Medicaid
ILENROLLEDMedicaid
MO0000808000Medicare PIN
MO0000808000Medicaid