Provider Demographics
NPI:1417226382
Name:ERNST, LIESEL
Entity Type:Individual
Prefix:
First Name:LIESEL
Middle Name:
Last Name:ERNST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 SISKIYOU BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6462
Mailing Address - Country:US
Mailing Address - Phone:541-200-2777
Mailing Address - Fax:541-214-2575
Practice Address - Street 1:2924 SISKIYOU BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6462
Practice Address - Country:US
Practice Address - Phone:541-200-2777
Practice Address - Fax:541-214-2575
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA184560363A00000X
CA55040363A00000X
MN1645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP01049458OtherMEDICARE - RAIL ROAD
MNP01049458OtherMEDICARE - RAIL ROAD