MEDICARE: SUZAN OLIVIA LISENBY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	11405437-1205	UT
2	208100000X	Physical Medicine & Rehabilitation Physician	2022033965	MO

General Provider Information

NPI Number	:	1629572771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZAN OLIVIA LISENBY MD

Provider Business Mailing Address
First Line	:	101 MOSAIC CT STE 300
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-0015
Country	:	US
Telephone Number	:	816-271-7673
Fax Number	:	816-271-4924

Provider Business Practice Location Address
First Line	:	101 MOSAIC CT STE 300
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-0015
Country	:	US
Telephone Number	:	816-271-7673
Fax Number	:	816-271-4924

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2018
Last Update Date	:	04/06/2026

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Directions to “ SUZAN OLIVIA LISENBY MD” Practice Location

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