Provider Demographics
NPI:1336131986
Name:PETERSON, LISA M (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1305
Mailing Address - Country:US
Mailing Address - Phone:414-219-7370
Mailing Address - Fax:414-219-7967
Practice Address - Street 1:945 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1305
Practice Address - Country:US
Practice Address - Phone:414-219-7370
Practice Address - Fax:414-219-7967
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2022-07-09
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
WI42769207RC0200X, 207RN0300X
WI42769-21207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43548700Medicaid
WI001571181Medicare PIN