Provider Demographics
NPI:1629364377
Name:MULLEN, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MULLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:497 W LOTT ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1658
Mailing Address - Country:US
Mailing Address - Phone:307-684-2228
Mailing Address - Fax:307-684-2177
Practice Address - Street 1:497 W LOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1658
Practice Address - Country:US
Practice Address - Phone:307-684-2228
Practice Address - Fax:307-684-2177
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-1172207Q00000X
WY9778A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine