Basic Information
| Provider Information | |||||||||
| NPI: | 1659397420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRUSAK | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | SITZMANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182495555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6351 E SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558042545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182495555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31997 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31860000 | 05 | WI | MEDICAID | 225090000 | 05 | MN | MEDICAID |