Individual
LISA R DAVIDSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1230 E MAIN STREET, MANKATO CLINIC AT MAIN STREET, MANKATO, MN 56002-8674
(507) 625-1811
Mailing address
PO BOX 8674, 1230 E MAIN ST MANKATO CLINIC LTD, MANKATO, MN 56002-8674
(507) 625-1811
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
43496
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0500173
MEDICA
MN
05
—
071645600
—
MN
01
—
0947127
MEDICAID
IA
01
—
130024186
RR MEDICARE
—
01
—
1328361
AMERICAS PPO
MN
01
—
151694
UCARE
MN
01
—
410849339 56001 C181
CHAMPUS
—
01
—
45D61DA
BCBS
MN
01
—
HP32997
HEALTH PARTNERS
MN
01
—
NA2951027572
PREFERRED ONE
MN
Enumeration date
01/10/2006
Last updated
07/10/2020
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