Provider Demographics
NPI:1558494146
Name:PENDLETON, LISA MARIE (RPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 S LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67210-2447
Mailing Address - Country:US
Mailing Address - Phone:316-945-8020
Mailing Address - Fax:316-616-0106
Practice Address - Street 1:3729 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4925
Practice Address - Country:US
Practice Address - Phone:316-945-8020
Practice Address - Fax:316-616-0106
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS6785OtherPREFERRED HEALTH SYSTEMS
KS140595OtherBCBS PROVIDER NUMBER
KSP00161405Medicare ID - Type UnspecifiedRR MEDICAR PROVIDER #
KS140595OtherBCBS PROVIDER NUMBER