Provider Demographics
NPI:1376586792
Name:BORDEAUX, LISA (CNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:BORDEAUX
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2522
Mailing Address - Country:US
Mailing Address - Phone:763-427-9980
Mailing Address - Fax:763-427-9908
Practice Address - Street 1:4040 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 120
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55433-2522
Practice Address - Country:US
Practice Address - Phone:763-427-9980
Practice Address - Fax:763-427-9908
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1222515363L00000X
MN3228363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN771170100Medicaid