Provider Demographics
NPI:1801340815
Name:MOSBY, LISA MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:MOSBY
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 1:1872 N TATE RD
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-6035
Mailing Address - Country:US
Mailing Address - Phone:870-918-0695
Mailing Address - Fax:870-862-2100
Practice Address - Street 1:214 HOPE LANDING RD
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-8725
Practice Address - Country:US
Practice Address - Phone:870-862-0500
Practice Address - Fax:870-862-2100
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPTA1777OtherPTA LICENSE NUMBER