Provider Demographics
NPI:1184930745
Name:TISA, LEE MICHAEL (DPM)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:MICHAEL
Last Name:TISA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 SUE ANN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2341
Mailing Address - Country:US
Mailing Address - Phone:262-248-9727
Mailing Address - Fax:
Practice Address - Street 1:502 SUE ANN DR
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2341
Practice Address - Country:US
Practice Address - Phone:262-248-9727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003410213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003410Medicaid
ILT37883Medicare UPIN