Healthcare Provider Details

I. General information

NPI: 1124292867
Provider Name (Legal Business Name): LISA RANKIN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 NW PRIMA VISTA BLVD SUITE 105
PORT ST LUCIE FL
34983-8786
US

IV. Provider business mailing address

499 NW PRIMA VISTA BLVD SUITE 105
PORT ST LUCIE FL
34983-8786
US

V. Phone/Fax

Practice location:
  • Phone: 772-344-1409
  • Fax: 772-344-9441
Mailing address:
  • Phone: 772-344-1409
  • Fax: 772-344-9441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0074325
License Number StateFL

VIII. Authorized Official

Name: DR. LISA M RANKIN
Title or Position: OWNER/AGENT
Credential: M.D., P.A.
Phone: 772-344-1409