Healthcare Provider Details

I. General information

NPI: 1780960864
Provider Name (Legal Business Name): LISA M BRAASCH CST/CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOUTHERN BAY DR
SAINT JOHNS FL
32259-6275
US

IV. Provider business mailing address

200 SOUTHERN BAY DR
SAINT JOHNS FL
32259-6275
US

V. Phone/Fax

Practice location:
  • Phone: 904-287-1918
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number84898
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: