Provider Demographics
NPI:1790886257
Name:GUZMAN, LISA J (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:GUZMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 PROVIDENT DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3291
Mailing Address - Country:US
Mailing Address - Phone:574-372-3800
Mailing Address - Fax:574-382-3810
Practice Address - Street 1:1520 PROVIDENT DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3291
Practice Address - Country:US
Practice Address - Phone:574-372-3800
Practice Address - Fax:574-372-3810
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000128A363LF0000X
IL209005979364SX0200X
IL209010163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN199790OtherMCARE PART A PROV #
IN626820OtherMCARE GROUP PROV #
IL437901OtherMCARE GROUP PROV #
IL209005979Medicaid
INP81117Medicare PIN
IL437901OtherMCARE GROUP PROV #