Healthcare Provider Details

I. General information

NPI: 1427105774
Provider Name (Legal Business Name): LISA M SALT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 US HIGHWAY 1 S STE 10
SAINT AUGUSTINE FL
32086-7000
US

IV. Provider business mailing address

4255 US HIGHWAY 1 S STE 10
ST AUGUSTINE FL
32086-7000
US

V. Phone/Fax

Practice location:
  • Phone: 904-240-0565
  • Fax: 904-240-0471
Mailing address:
  • Phone: 904-240-0565
  • Fax: 904-240-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103852
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: