Healthcare Provider Details

I. General information

NPI: 1679951438
Provider Name (Legal Business Name): LISA MARIE ANTONIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 TONGASS DR
SITKA AK
99835
US

IV. Provider business mailing address

3100 CHANNEL DR STE 300
JUNEAU AK
99801-7837
US

V. Phone/Fax

Practice location:
  • Phone: 907-966-8318
  • Fax: 907-966-8606
Mailing address:
  • Phone: 907-463-4074
  • Fax: 907-463-1510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMED-RES-LIC 52169
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number134059
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: