Provider Demographics
NPI:1720075666
Name:BRAUN, LISA R (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:BRAUN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:104 W 3RD STREET
Mailing Address - City:ROSHOLT
Mailing Address - State:SD
Mailing Address - Zip Code:57260-0021
Mailing Address - Country:US
Mailing Address - Phone:605-537-4350
Mailing Address - Fax:
Practice Address - Street 1:332 2ND AVE N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4528
Practice Address - Country:US
Practice Address - Phone:701-642-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0493363A00000X
MN9723363A00000X
NDPAC0387363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6824570Medicaid
SD40113Medicare ID - Type Unspecified
SD6824570Medicaid