Provider Demographics
NPI:1528388899
Name:KWISNEK-LAMANTIA, LISA M (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:KWISNEK-LAMANTIA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:KWISNEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:25 COLONY BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-7971
Mailing Address - Country:US
Mailing Address - Phone:724-459-9111
Mailing Address - Fax:724-459-7856
Practice Address - Street 1:25 COLONY BLVD STE 102
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-7971
Practice Address - Country:US
Practice Address - Phone:724-459-9111
Practice Address - Fax:724-459-7856
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015137208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024757490002Medicaid
PA1024757490002Medicaid