Provider Demographics
NPI:1780687566
Name:MCCLUSKEY, LISA LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:LOUISE
Last Name:MCCLUSKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:LOUISE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9555 SW BARNES RD
Mailing Address - Street 2:STE 150
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6663
Mailing Address - Country:US
Mailing Address - Phone:503-297-7403
Mailing Address - Fax:503-297-3096
Practice Address - Street 1:9555 SW BARNES RD
Practice Address - Street 2:STE 150
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6663
Practice Address - Country:US
Practice Address - Phone:503-297-7403
Practice Address - Fax:503-297-3096
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21717207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1018856Medicaid
OR134018Medicaid
WAG8889403Medicare PIN
ORG90135Medicare UPIN
WA1018856Medicaid