Provider Demographics
NPI:1619935616
Name:PERSYN, LISA DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DIANE
Last Name:PERSYN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19016 STONE OAK PKWY STE 280
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3337
Mailing Address - Country:US
Mailing Address - Phone:210-545-5128
Mailing Address - Fax:210-545-5120
Practice Address - Street 1:12180 N MOPAC EXPY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2909
Practice Address - Country:US
Practice Address - Phone:512-836-8800
Practice Address - Fax:512-836-8801
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3778208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K2535OtherBLUE CROSS BLUE SHIELD
TX177678301Medicaid
I45232Medicare UPIN
TX320017YX50Medicare PIN
TX177678301Medicaid
TX320017YVYMMedicare PIN