Provider Demographics
NPI:1720028111
Name:PUMA, LISA (PMHNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PUMA
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8635 SW 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3318
Mailing Address - Country:US
Mailing Address - Phone:503-452-9803
Mailing Address - Fax:503-452-2872
Practice Address - Street 1:610 SW ALDER ST
Practice Address - Street 2:SUITE 915
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3625
Practice Address - Country:US
Practice Address - Phone:503-830-1624
Practice Address - Fax:503-452-2872
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087006211N6363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR090511Medicaid
OR223347Medicaid
ORP091490Medicare UPIN
116185Medicare ID - Type Unspecified
OR116185Medicare PIN