Provider Demographics
NPI:1629035308
Name:STABER, LISA DEETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DEETTE
Last Name:STABER
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 1:20635 MISHAWAKA SHORES TRL
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-6071
Mailing Address - Country:US
Mailing Address - Phone:218-398-0256
Mailing Address - Fax:
Practice Address - Street 1:20635 MISHAWAKA SHORES TRL
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-6071
Practice Address - Country:US
Practice Address - Phone:218-398-0256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086765207Q00000X
WI38751-020207Q00000X
MN38922207Q00000X
WI38751-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4848740Medicaid
P00328166OtherRR-MEDICARE
MIP00328166OtherRR-MEDICARE
P00328166OtherRR-MEDICARE
MIF80212Medicare UPIN
MI4825080002Medicare NSC
F80212Medicare UPIN
4825080002Medicare NSC