Healthcare Provider Details

I. General information

NPI: 1912916891
Provider Name (Legal Business Name): LISA S BOSSHARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 VETERANS AVE STE 106
WEST BEND WI
53090-2545
US

IV. Provider business mailing address

9000 W. WISCONSIN AVENUE MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 262-353-4460
  • Fax: 262-353-4461
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41313
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: