Provider Demographics
NPI:1023289881
Name:GENGO, LISA J (ND, PAC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:J
Last Name:GENGO
Suffix:
Gender:F
Credentials:ND, PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 KNIGHT ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-4720
Mailing Address - Country:US
Mailing Address - Phone:914-419-7585
Mailing Address - Fax:
Practice Address - Street 1:8 KNIGHT ST
Practice Address - Street 2:SUITE 205
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4720
Practice Address - Country:US
Practice Address - Phone:914-419-7585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004185363A00000X
CT00310175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No175F00000XOther Service ProvidersNaturopath