Provider Demographics
NPI:1134412794
Name:LISNER, MORGAN MELLISANDE (MD)
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:MELLISANDE
Last Name:LISNER
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 1:6355 NE CORNELL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5434
Mailing Address - Country:US
Mailing Address - Phone:503-597-3130
Mailing Address - Fax:503-597-3140
Practice Address - Street 1:6355 NE CORNELL RD STE 100
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5434
Practice Address - Country:US
Practice Address - Phone:503-597-3130
Practice Address - Fax:503-597-3140
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD196628207Q00000X
TN52984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ019173Medicaid
MO1134412794Medicaid
AR212922001Medicaid
GA003181727AMedicaid
AL184972Medicaid
MS05624779Medicaid