Provider Demographics
NPI:1275307993
Name:MARCINKOSKI, LISA (PA, MMS)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:MARCINKOSKI
Suffix:
Gender:F
Credentials:PA, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7246 NW 1ST MNR
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2267
Mailing Address - Country:US
Mailing Address - Phone:954-288-2919
Mailing Address - Fax:
Practice Address - Street 1:6000 GLADES RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-7208
Practice Address - Country:US
Practice Address - Phone:561-509-5394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9102558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant