Provider Demographics
NPI:1265511208
Name:GIACCONE, LISA (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GIACCONE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:TAMBURRINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:20 PEACHTREE CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:20 PEACHTREE CT
Practice Address - Street 2:SUITE 105
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4616
Practice Address - Country:US
Practice Address - Phone:631-467-3700
Practice Address - Fax:631-467-0928
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ93K0ZWVP1Medicare PIN
NYQ93K01Medicare PIN