MEDICARE: LISA B NEWCOMER CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician	1075	MN
2	363L00000X	Nurse Practitioner	1075	MN

General Provider Information

NPI Number	:	1326376096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA B NEWCOMER CNP

Provider Business Mailing Address
First Line	:	2104 NORTHDALE BLVD NW
Second Line	:	SUITE 220
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55433-3028
Country	:	US
Telephone Number	:	763-537-6000
Fax Number	:	763-537-6666

Provider Business Practice Location Address
First Line	:	9550 UPLAND LN N
Second Line	:	SUITE 100
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-4481
Country	:	US
Telephone Number	:	763-537-6000
Fax Number	:	763-537-6666

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2009
Last Update Date	:	02/13/2019

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