Provider Demographics
NPI:1700883303
Name:BREISACHER, LISA G (LNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:BREISACHER
Suffix:
Gender:F
Credentials:LNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 LINCOLN WAY
Mailing Address - Street 2:315
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2527
Mailing Address - Country:US
Mailing Address - Phone:208-625-6000
Mailing Address - Fax:
Practice Address - Street 1:1919 LINCOLN WAY
Practice Address - Street 2:315
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2527
Practice Address - Country:US
Practice Address - Phone:208-625-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP399A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805545800Medicaid
S53361Medicare UPIN