Provider Demographics
NPI:1578522694
Name:COONEY, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:COONEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1751 E GARDNER WAY
Mailing Address - Street 2:SUITE E
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-376-1633
Mailing Address - Fax:907-376-7864
Practice Address - Street 1:1751 E GARDNER WAY
Practice Address - Street 2:SUITE E
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-376-1633
Practice Address - Fax:907-376-7864
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK3925207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3925Medicaid
AKMD3925Medicaid
AK150042Medicare ID - Type Unspecified
AKK16073Medicare PIN