Provider Demographics
NPI:1629572771
Name:LISENBY, SUZAN OLIVIA (MD)
Entity Type:Individual
Prefix:
First Name:SUZAN
Middle Name:OLIVIA
Last Name:LISENBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1066
Mailing Address - Fax:816-271-6786
Practice Address - Street 1:5301 FARAON ST STE 200
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3829
Practice Address - Country:US
Practice Address - Phone:816-271-7673
Practice Address - Fax:816-271-4924
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT11405437-1205208100000X
MO2022033965208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation