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Individual
LISA MARIE ANTONIO
Active
Individual
LISA MARIE ANTONIO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
134059
AK
390200000X
Student in an Organized Health Care Education/Training Program
MED-RES-LIC 52169
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
134059
STATE LICENSE
AK
Enumeration date
05/13/2015
Last updated
10/08/2018
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