Provider Demographics
NPI:1972795920
Name:LISS, MARA LAUREN (MD)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:LAUREN
Last Name:LISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 BROWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1012
Mailing Address - Country:US
Mailing Address - Phone:763-234-6632
Mailing Address - Fax:
Practice Address - Street 1:14001 RIDGEDALE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1753
Practice Address - Country:US
Practice Address - Phone:952-473-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN53077208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics