Provider Demographics
NPI:1417111337
Name:ROLLISON, LISA MARIE PRATHER (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE PRATHER
Last Name:ROLLISON
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 1:1601 E BROADWAY STE 240
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8022
Mailing Address - Country:US
Mailing Address - Phone:573-815-8145
Mailing Address - Fax:573-815-3832
Practice Address - Street 1:1601 E BROADWAY STE 240
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8022
Practice Address - Country:US
Practice Address - Phone:573-815-8145
Practice Address - Fax:573-815-3832
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011014242208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO151560003Medicare PIN