Provider Demographics
NPI:1013998475
Name:LISSY, ERNEST EUGENE (FNP)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:EUGENE
Last Name:LISSY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:E
Other - Last Name:LISSY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:1375 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-2099
Mailing Address - Country:US
Mailing Address - Phone:503-769-2641
Mailing Address - Fax:503-769-3797
Practice Address - Street 1:1375 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-2099
Practice Address - Country:US
Practice Address - Phone:503-769-2641
Practice Address - Fax:503-769-3797
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450135NP FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily