Provider Demographics
NPI:1720021264
Name:MEDGANSIS, LISA (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:MEDGANSIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 S PATRICK DR
Mailing Address - Street 2:STE 3
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4400
Mailing Address - Country:US
Mailing Address - Phone:321-773-8155
Mailing Address - Fax:321-773-8154
Practice Address - Street 1:2030 S PATRICK DR
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4400
Practice Address - Country:US
Practice Address - Phone:321-773-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT6390225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT-6390OtherSTATE OF FL. PT LICENSE
FLK3234Medicare ID - Type UnspecifiedMEDICARE GROUP ID
FLPT-6390OtherSTATE OF FL. PT LICENSE