Provider Demographics
NPI:1700875432
Name:SHORTER, LISA A (MS PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:SHORTER
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BURKHART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS PT
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:MD
Mailing Address - Zip Code:20758-0160
Mailing Address - Country:US
Mailing Address - Phone:301-860-0237
Mailing Address - Fax:301-860-0076
Practice Address - Street 1:3140 W WARD RD STE 203
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-3047
Practice Address - Country:US
Practice Address - Phone:410-286-7205
Practice Address - Fax:410-286-7206
Is Sole Proprietor?:No
Enumeration Date:2005-10-15
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD20258OtherPHYS. THERAPY LICENSE NO.
MD00B402E22Medicare ID - Type Unspecified