Basic Information
| Provider Information | |||||||||
| NPI: | 1659734390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 BLACKMORE RD | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826093345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336000 | ||||||||
| FaxNumber: | 3072336089 | ||||||||
| Practice Location | |||||||||
| Address1: | 5647 US HIGHWAY 26 | ||||||||
| Address2: | |||||||||
| City: | DUBOIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825139607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074552516 | ||||||||
| FaxNumber: | 3074552526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 22672.1509 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 144824200 | 05 | WY | MEDICAID |