Provider Demographics
NPI:1134301039
Name:LISJAK, GEORGE ANDREW (DC)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ANDREW
Last Name:LISJAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:GOWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14070-1415
Mailing Address - Country:US
Mailing Address - Phone:716-532-6000
Mailing Address - Fax:716-532-6000
Practice Address - Street 1:15 SOUTH WATER ST
Practice Address - Street 2:
Practice Address - City:GOWANDA
Practice Address - State:NY
Practice Address - Zip Code:14070
Practice Address - Country:US
Practice Address - Phone:716-532-6000
Practice Address - Fax:716-532-6000
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYY3888111N00000X
GACHIR007522111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT25929Medicare UPIN