Provider Demographics
NPI:1093898991
Name:GENTZLER, LISA LEANNE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LEANNE
Last Name:GENTZLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5307 YELLOWSTONE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4736
Mailing Address - Country:US
Mailing Address - Phone:307-632-7677
Mailing Address - Fax:307-778-8292
Practice Address - Street 1:5307 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4736
Practice Address - Country:US
Practice Address - Phone:307-632-7677
Practice Address - Fax:307-778-8292
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT 1072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY313800OtherBLUE CROSS/BLUE SHIELD
WY313800OtherBLUE CROSS/BLUE SHIELD
WY20455Medicare ID - Type Unspecified