Provider Demographics
NPI:1619963709
Name:JOHNSON, LISA M (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:HASSEBROEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7120 S 69TH ST STE 101A
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3868
Mailing Address - Country:US
Mailing Address - Phone:402-499-2883
Mailing Address - Fax:833-471-5257
Practice Address - Street 1:7120 S 69TH ST STE 101A
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3868
Practice Address - Country:US
Practice Address - Phone:402-520-8955
Practice Address - Fax:833-471-5257
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE23174OtherBCBS
NEP00716684OtherRAILROAD MEDICARE
NE098762Medicare PIN