Provider Demographics
NPI:1477645083
Name:PUTNEY, LISA ELLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ELLEN
Last Name:PUTNEY
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 1:1005 LAKE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3921
Mailing Address - Country:US
Mailing Address - Phone:218-751-2458
Mailing Address - Fax:
Practice Address - Street 1:403 AMERICA AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3122
Practice Address - Country:US
Practice Address - Phone:218-444-8727
Practice Address - Fax:218-444-8546
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41406204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0000LBGVZMedicare ID - Type Unspecified
MNG25954Medicare UPIN