Healthcare Provider Details

I. General information

NPI: 1598706970
Provider Name (Legal Business Name): LISA NIELSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CRYSTAL RD
ISLAND FALLS ME
04747-4369
US

IV. Provider business mailing address

PO BOX 500
PATTEN ME
04765-0500
US

V. Phone/Fax

Practice location:
  • Phone: 207-463-3600
  • Fax: 207-463-3603
Mailing address:
  • Phone: 207-528-2285
  • Fax: 207-528-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number013731
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: