Provider Demographics
NPI:1558725093
Name:LISMAN, PETER (ATC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LISMAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 YORK ROAD
Mailing Address - Street 2:DEPARTMENT OF KINESIOLOGY
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8000 YORK RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21252-0001
Practice Address - Country:US
Practice Address - Phone:410-704-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00007242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer