Provider Demographics
NPI:1790928489
Name:ROSBOROUGH, LISA MICHELE (NP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELE
Last Name:ROSBOROUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:MERITT-ITEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:78763 RAT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-9421
Mailing Address - Country:US
Mailing Address - Phone:541-942-6475
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:912-663-3586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-11
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN156565363LF0000X
OR201350102NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I507764OtherMEDICARE
GA754611424AMedicaid