Healthcare Provider Details

I. General information

NPI: 1467758557
Provider Name (Legal Business Name): LISA MARIE WRIGHT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4799 ESSEX CIR
BOULDER CO
80301-4136
US

IV. Provider business mailing address

4799 ESSEX CIR
BOULDER CO
80301-4136
US

V. Phone/Fax

Practice location:
  • Phone: 970-390-5525
  • Fax:
Mailing address:
  • Phone: 970-390-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number014506
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3368
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: