Provider Demographics
NPI:1912642588
Name:LISA BOFFA P.L.L.C.
Entity Type:Organization
Organization Name:LISA BOFFA P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOFFA
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, FNP, PMHNP, ND
Authorized Official - Phone:970-964-8653
Mailing Address - Street 1:715 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3914
Mailing Address - Country:US
Mailing Address - Phone:970-964-8653
Mailing Address - Fax:970-249-8495
Practice Address - Street 1:715 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3914
Practice Address - Country:US
Practice Address - Phone:970-964-8653
Practice Address - Fax:970-249-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-28
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1942508635Medicaid