Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | A114046 | IA |
NPI | 1003054305 |
---|---|
Provider Name | Lisa Lynn Maher |
First Address | Waterloo, IA 50704-2758 |
Second Address | Waterloo, IA 50703-1223 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2009 |
Last Update Date | 14/10/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003054305 | (05) | IA |
1003054305 | WELLMARK BCBS (01) | IA |
421417307-UZ | UHC/RIVER VALLEY/JD (01) | IA |
P00704358 (PTAN) | RR MEDICARE (01) | IA |