Provider Demographics
NPI:1235330960
Name:GLEASON, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GLEASON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 MORRO AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-2233
Mailing Address - Country:US
Mailing Address - Phone:805-772-7313
Mailing Address - Fax:805-772-0395
Practice Address - Street 1:685 MORRO AVE STE C
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-2233
Practice Address - Country:US
Practice Address - Phone:805-772-7313
Practice Address - Fax:805-772-0395
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108043208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB255979OtherMEDICARE PTAN