Provider Demographics
NPI:1538351606
Name:LISENBEY, EDWARD ALAN (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ALAN
Last Name:LISENBEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 W POPLAR ST
Practice Address - Street 2:PSMMC ER
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2846
Practice Address - Country:US
Practice Address - Phone:509-522-5802
Practice Address - Fax:509-522-5541
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60085902207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500615356Medicaid
WA1538351606Medicaid
WA1538351606Medicaid