Provider Demographics
NPI:1780637538
Name:O'BRIEN, LISA A (PA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E RYAN RD
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4563
Mailing Address - Country:US
Mailing Address - Phone:414-570-3590
Mailing Address - Fax:
Practice Address - Street 1:200 E RYAN RD
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-4563
Practice Address - Country:US
Practice Address - Phone:414-570-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42876500Medicaid
0089S73601Medicare ID - Type Unspecified
WI42876500Medicaid