Provider Demographics
NPI:1619127511
Name:YIRKA, LISA GWEN (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GWEN
Last Name:YIRKA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 TUCKER RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:WA
Mailing Address - Zip Code:98591-8685
Mailing Address - Country:US
Mailing Address - Phone:360-623-0319
Mailing Address - Fax:
Practice Address - Street 1:800 TUCKER RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:WA
Practice Address - Zip Code:98591-8685
Practice Address - Country:US
Practice Address - Phone:360-623-0319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160031772225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP160031772OtherPTA LICENSE