Provider Demographics
NPI:1801297189
Name:GARDISSER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GARDISSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 HWY 56 E
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:GA
Mailing Address - Zip Code:30436-4358
Mailing Address - Country:US
Mailing Address - Phone:912-293-0056
Mailing Address - Fax:
Practice Address - Street 1:2646 HWY 56 E
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-4358
Practice Address - Country:US
Practice Address - Phone:912-293-0056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography