Provider Demographics
NPI:1245612522
Name:LISTER, BROCK
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:LISTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 E WHITING ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4136
Mailing Address - Country:US
Mailing Address - Phone:716-523-1783
Mailing Address - Fax:
Practice Address - Street 1:802 E WHITING ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-4136
Practice Address - Country:US
Practice Address - Phone:716-523-1783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31894225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist