Healthcare Provider Details

I. General information

NPI: 1699600452
Provider Name (Legal Business Name): MARK LISAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 E BUTLER AVE
FLAGSTAFF AZ
86004-0009
US

IV. Provider business mailing address

3112 E BUTLER AVE
FLAGSTAFF AZ
86004-0009
US

V. Phone/Fax

Practice location:
  • Phone: 860-519-7902
  • Fax: 502-212-8502
Mailing address:
  • Phone: 860-519-7902
  • Fax: 502-212-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0047313
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: