Provider Demographics
NPI:1598706970
Name:NIELSEN, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:PATTEN
Mailing Address - State:ME
Mailing Address - Zip Code:04765-0500
Mailing Address - Country:US
Mailing Address - Phone:207-528-2285
Mailing Address - Fax:207-528-2880
Practice Address - Street 1:1300 CRYSTAL RD
Practice Address - Street 2:
Practice Address - City:ISLAND FALLS
Practice Address - State:ME
Practice Address - Zip Code:04747-4369
Practice Address - Country:US
Practice Address - Phone:207-463-3600
Practice Address - Fax:207-463-3603
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP00301812OtherRR MEDICARE
ME203814OtherNHIC GROUP PTAN
ME298050099Medicaid
ME5236796OtherCIGNA
ME144828OtherAETNA GROUP
ME119411700OtherFEDERAL W/C GROUP
ME048673OtherANTHEM STAR #
MEF77297OtherHARVARD PILGRAM
MEF77297Medicare UPIN
ME5236796OtherCIGNA