Provider Demographics
NPI:1174524912
Name:BUSHNELL, LISA K (CFNP)
Entity type:Individual
Prefix:MISS
First Name:LISA
Middle Name:K
Last Name:BUSHNELL
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
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Mailing Address - Street 1:7300 RANCH ROAD 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3255
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-628-0468
Practice Address - Street 1:1353 PASEO DEL PUEBLO SUR STE D
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5958
Practice Address - Country:US
Practice Address - Phone:575-613-8090
Practice Address - Fax:575-613-8091
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01307363LF0000X, 363LF0000X
NMR54485207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
QMP000003404562OtherMOLINA
10021342OtherCIGNA / LOVELACE
NM5670349Medicaid
NM00NM006H13OtherBLUE MEDICARE
202024643OtherPRESBYTERIAN
7722751OtherAETNA
NM006H13OtherBLUE CROSS & BLUE SHIELD
NM00051474Medicaid