Provider Demographics
NPI:1841742004
Name:MARTIS, LISA (APNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MARTIS
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 S TAYLOR DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-8495
Mailing Address - Country:US
Mailing Address - Phone:920-457-2917
Mailing Address - Fax:
Practice Address - Street 1:3711 S TAYLOR DR
Practice Address - Street 2:SUITE 104
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-8495
Practice Address - Country:US
Practice Address - Phone:920-457-2917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6970 - 33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1841742004Medicaid