Healthcare Provider Details

I. General information

NPI: 1740580539
Provider Name (Legal Business Name): LISA MARIE WRIGHT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 1ST STREET
LIMON CO
80828-1120
US

IV. Provider business mailing address

414 PLYMOUTH NE
GRAND RAPIDS MI
49505-6038
US

V. Phone/Fax

Practice location:
  • Phone: 719-775-2367
  • Fax: 719-775-2365
Mailing address:
  • Phone: 616-454-3465
  • Fax: 616-242-7060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3018
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: