Provider Demographics
NPI:1255571626
Name:TYRKA, LISA (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TYRKA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2442
Mailing Address - Country:US
Mailing Address - Phone:518-281-1045
Mailing Address - Fax:
Practice Address - Street 1:1733 ROUTE 9
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2442
Practice Address - Country:US
Practice Address - Phone:518-281-1045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014413174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist