Provider Demographics
NPI:1700253457
Name:KRAUS, LISA (LMP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KRAUS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7046 FLUTE ST SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-5053
Mailing Address - Country:US
Mailing Address - Phone:334-447-8814
Mailing Address - Fax:
Practice Address - Street 1:4510 INTELCO LOOP SE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6005
Practice Address - Country:US
Practice Address - Phone:360-402-6776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA6052126171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor