Healthcare Provider Details

I. General information

NPI: 1124436787
Provider Name (Legal Business Name): LISA MAST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 E PAWNEE ST
WICHITA KS
67207-5475
US

IV. Provider business mailing address

8080 E PAWNEE ST
WICHITA KS
67207-5475
US

V. Phone/Fax

Practice location:
  • Phone: 316-682-0004
  • Fax: 316-683-5932
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-01559
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: