Provider Demographics
NPI:1629646179
Name:MEDINA, LISA L (NP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:L
Last Name:MEDINA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 KIPLING ST UNIT 220
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2897
Mailing Address - Country:US
Mailing Address - Phone:303-424-0559
Mailing Address - Fax:
Practice Address - Street 1:4251 KIPLING ST UNIT 220
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2897
Practice Address - Country:US
Practice Address - Phone:303-424-0559
Practice Address - Fax:303-424-0205
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0996552-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner