Provider Demographics
NPI:1336554534
Name:BURSON, LISA (DPM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BURSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1187 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-3081
Mailing Address - Country:US
Mailing Address - Phone:810-969-4016
Mailing Address - Fax:810-969-4021
Practice Address - Street 1:1187 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3081
Practice Address - Country:US
Practice Address - Phone:810-969-4016
Practice Address - Fax:810-969-4021
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002521213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery