Healthcare Provider Details

I. General information

NPI: 1790604247
Provider Name (Legal Business Name): LISA WIDDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9550 UPLAND LN N STE 230
MAPLE GROVE MN
55369-4484
US

IV. Provider business mailing address

4420 118TH AVE NE
BLAINE MN
55449-5857
US

V. Phone/Fax

Practice location:
  • Phone: 952-920-2730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1252967
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: