Provider Demographics
NPI:1982682811
Name:WHEATLEY, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-342-2134
Mailing Address - Fax:541-686-6021
Practice Address - Street 1:920 COUNTRY CLUB RD
Practice Address - Street 2:STE 200A
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6024
Practice Address - Country:US
Practice Address - Phone:541-342-2134
Practice Address - Fax:541-686-6021
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21920207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134129Medicaid
OR134129Medicaid
ORR136525Medicare PIN