Provider Demographics
NPI:1740580539
Name:WRIGHT, LISA MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:414 PLYMOUTH NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6038
Mailing Address - Country:US
Mailing Address - Phone:616-454-3465
Mailing Address - Fax:616-242-7060
Practice Address - Street 1:820 1ST STREET
Practice Address - Street 2:
Practice Address - City:LIMON
Practice Address - State:CO
Practice Address - Zip Code:80828-1120
Practice Address - Country:US
Practice Address - Phone:719-775-2367
Practice Address - Fax:719-775-2365
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2015-07-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO3018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3018OtherMEDICAL LICENSE