Provider Demographics
NPI:1598798316
Name:GUSHWA, LISA LEE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LEE
Last Name:GUSHWA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LEE
Other - Last Name:GUSHWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:935 HIGHLAND BLVD
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6904
Mailing Address - Country:US
Mailing Address - Phone:406-587-5123
Mailing Address - Fax:406-586-8591
Practice Address - Street 1:935 HIGHLAND BLVD STE 2200
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6915
Practice Address - Country:US
Practice Address - Phone:406-414-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00457901OtherRAILROAD MEDICARE
AZ978992Medicaid
AZZ111515Medicare PIN
AZI46725Medicare UPIN