Provider Demographics
NPI:1871595421
Name:RUPERT, LISA MAE (MSN FNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MAE
Last Name:RUPERT
Suffix:
Gender:F
Credentials:MSN FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MAE
Other - Last Name:MCLAUGHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5375
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:8170 33RD AVE S MS 21110Q
Practice Address - Street 2:HEALTHPARTNERS FLOATING CLINIC C/O PHYSICIAN SERVICES
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55440-1309
Practice Address - Country:US
Practice Address - Phone:952-883-5375
Practice Address - Fax:952-883-5395
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR165885-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN51915560Medicaid
500002669Medicare ID - Type Unspecified
Q20272Medicare UPIN