Provider Demographics
NPI:1912962788
Name:EVEN, LISA A (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:EVEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 S LOGAN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GREGORY
Mailing Address - State:SD
Mailing Address - Zip Code:57533-1614
Mailing Address - Country:US
Mailing Address - Phone:605-835-9611
Mailing Address - Fax:605-835-8033
Practice Address - Street 1:110 S LOGAN AVE STE A
Practice Address - Street 2:
Practice Address - City:GREGORY
Practice Address - State:SD
Practice Address - Zip Code:57533-1614
Practice Address - Country:US
Practice Address - Phone:605-835-9611
Practice Address - Fax:605-835-8033
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE22311207Q00000X
SD5085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5611310Medicaid
SD40604Medicare ID - Type Unspecified
SD5611310Medicaid