Provider Demographics
NPI:1386750099
Name:DEMARAIS, LISA MARIE (OPA-C, CST)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:DEMARAIS
Suffix:
Gender:F
Credentials:OPA-C, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 HART BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8538
Mailing Address - Country:US
Mailing Address - Phone:763-295-2921
Mailing Address - Fax:763-271-3810
Practice Address - Street 1:1107 HART BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8538
Practice Address - Country:US
Practice Address - Phone:763-295-2921
Practice Address - Fax:763-271-3810
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
MN875363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical