Provider Demographics
NPI:1750376083
Name:WILLIAMS, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILLIAMS
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:P.O. BOX 1000
Mailing Address - Street 2:1443 BECK AVENUE
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3423
Mailing Address - Country:US
Mailing Address - Phone:307-527-7811
Mailing Address - Fax:307-527-7396
Practice Address - Street 1:1443 BECK AVENUE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3423
Practice Address - Country:US
Practice Address - Phone:307-527-7811
Practice Address - Fax:307-527-7396
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6662A174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117167400Medicaid
WY117167400Medicaid
WYE96055Medicare UPIN