Provider Demographics
NPI:1679834956
Name:EGENES, LISA MARIE (CERTIFIED REGISTERED)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:EGENES
Suffix:
Gender:F
Credentials:CERTIFIED REGISTERED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MADISON AVE STE 311
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-2421
Mailing Address - Country:US
Mailing Address - Phone:507-345-2623
Mailing Address - Fax:
Practice Address - Street 1:1400 MADISON AVE STE 311
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-345-2623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1705249367500000X
NY655587367500000X
MN387367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered