Provider Demographics
NPI:1538604343
Name:BOOKTER, LISA BETH (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
Last Name:BOOKTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 S ERIE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-2907
Mailing Address - Country:US
Mailing Address - Phone:316-847-2812
Mailing Address - Fax:
Practice Address - Street 1:850 S ERIE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-2907
Practice Address - Country:US
Practice Address - Phone:316-847-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-00174225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS14-00174Medicaid