Provider Demographics
NPI:1457471377
Name:LISKO, TRINA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:TRINA
Middle Name:MARIE
Last Name:LISKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 EGG HARBOR RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2326
Mailing Address - Country:US
Mailing Address - Phone:856-589-0650
Mailing Address - Fax:856-589-2720
Practice Address - Street 1:556 EGG HARBOR RD
Practice Address - Street 2:SUITE A
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2326
Practice Address - Country:US
Practice Address - Phone:856-589-0650
Practice Address - Fax:856-589-2720
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014298208100000X
NJ25MB0842700208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102212120-0002Medicaid
PA141297HY8Medicare PIN
NJ139148Medicare PIN