Provider Demographics
NPI:1992016844
Name:LISK, MATTHEW TYLER SR (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TYLER
Last Name:LISK
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1840 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2808
Mailing Address - Country:US
Mailing Address - Phone:540-536-2270
Mailing Address - Fax:540-536-7847
Practice Address - Street 1:1840 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601
Practice Address - Country:US
Practice Address - Phone:540-536-2270
Practice Address - Fax:540-536-7847
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016420207R00000X
VA0102204917208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist