Provider Demographics
NPI:1669633434
Name:LANDA, LISA JOY (PTA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JOY
Last Name:LANDA
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:PO BOX 1262
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-1262
Mailing Address - Country:US
Mailing Address - Phone:307-324-5061
Mailing Address - Fax:
Practice Address - Street 1:1115 13TH ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-4610
Practice Address - Country:US
Practice Address - Phone:307-324-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-0129225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant