MEDICARE: LISA A KORBAN FNP, APNP

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	363LP2300X	Primary Care Nurse Practitioner	2404-033	WI

General Provider Information

NPI Number	:	1932193638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A KORBAN FNP, APNP

Provider Business Mailing Address
First Line	:	4425 N PORT WASHINGTON RD
Second Line	:	ATTN: CSMCP CLINIC CREDENTIALING
City	:	GLENDALE
State	:	WI
Zip	:	53212-1082
Country	:	US
Telephone Number	:	414-271-1633
Fax Number	:	414-271-5071

Provider Business Practice Location Address
First Line	:	2350 N LAKE DR
Second Line	:	SUITE 400
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4528
Country	:	US
Telephone Number	:	414-271-1633
Fax Number	:	414-271-5071

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

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	11/15/2011

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