Provider Demographics
NPI:1912932716
Name:LISA COONEY, MD-PC
Entity Type:Organization
Organization Name:LISA COONEY, MD-PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:COONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-376-1633
Mailing Address - Street 1:1751 E. GARDNER WAY
Mailing Address - Street 2:SUITE E
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-376-1633
Mailing Address - Fax:907-376-7864
Practice Address - Street 1:1751 GARDNER WAY
Practice Address - Street 2:SUITE E
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6513
Practice Address - Country:US
Practice Address - Phone:907-376-1633
Practice Address - Fax:907-376-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3925Medicaid
P0157517OtherRRMEDICARE