Provider Demographics
NPI:1720519499
Name:GAUTHIER, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10611 HYACINTH ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-4662
Mailing Address - Country:US
Mailing Address - Phone:303-547-4888
Mailing Address - Fax:
Practice Address - Street 1:2500 S HAVANA ST
Practice Address - Street 2:WATERPARK 1
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1618
Practice Address - Country:US
Practice Address - Phone:303-614-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO01736261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center