MEDICARE: DR. LISA ELLEN GRAHAM MSTOM

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	171100000X	Acupuncturist	AP2651	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AP2651	OTHER	FL	ACUPUNCTURE PHYSICIAN LICENSE

General Provider Information

NPI Number	:	1750518460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA ELLEN GRAHAM MSTOM

Provider Business Mailing Address
First Line	:	5120 CARILLO ST
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2060
Country	:	US
Telephone Number	:	305-740-5547
Fax Number	:

Provider Business Practice Location Address
First Line	:	6301 SUNSET DR
Second Line	:	SUITE 201
City	:	SOUTH MIAMI
State	:	FL
Zip	:	33143-4818
Country	:	US
Telephone Number	:	305-669-2715
Fax Number	:

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

Provider Enumeration Date	:	06/20/2009
Last Update Date	:	06/20/2009

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