Provider Demographics
NPI:1629240536
Name:JOERRES, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:JOERRES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:BOSNJAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13950 W CAPITOL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2441
Mailing Address - Country:US
Mailing Address - Phone:262-781-3065
Mailing Address - Fax:262-781-3835
Practice Address - Street 1:13950 W CAPITOL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2441
Practice Address - Country:US
Practice Address - Phone:262-781-3065
Practice Address - Fax:262-781-3835
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53832208000000X
WI1629240536208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629240536Medicaid