1558300830 NPI number — LISA I MANSUR MD

Table of content: LISA I MANSUR MD (NPI 1558300830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558300830 NPI number — LISA I MANSUR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANSUR
Provider First Name:
LISA
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558300830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3401 PLANTATION DR
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68516-4712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-328-8863
Provider Business Mailing Address Fax Number:
402-328-8078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 PLANTATION DR
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68516-4712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-328-8863
Provider Business Practice Location Address Fax Number:
402-328-8078
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  20419 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10025031300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00057124 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: P00057124 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com