Provider Demographics
NPI:1174723779
Name:OBERG, LISA A (NPP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:OBERG
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CENTURY HILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2151
Mailing Address - Country:US
Mailing Address - Phone:518-713-4595
Mailing Address - Fax:518-713-4595
Practice Address - Street 1:11 CENTURY HILL DRIVE
Practice Address - Street 2:SUITE 206
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2151
Practice Address - Country:US
Practice Address - Phone:518-713-4595
Practice Address - Fax:518-713-4598
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401070363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB6460Medicare PIN