Provider Demographics
NPI:1275593923
Name:LISOWE, JENNIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:LISOWE
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 1:5067 55TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3809
Mailing Address - Country:US
Mailing Address - Phone:507-288-3443
Mailing Address - Fax:507-529-6622
Practice Address - Street 1:5067 55TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3809
Practice Address - Country:US
Practice Address - Phone:507-288-3443
Practice Address - Fax:507-529-6622
Is Sole Proprietor?:No
Enumeration Date:2006-03-26
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41670207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN685224600Medicaid
G96996Medicare UPIN
MN685224600Medicaid