Provider Demographics
NPI:1104887587
Name:LISITSKY, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:LISITSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-4464
Mailing Address - Country:US
Mailing Address - Phone:716-693-0556
Mailing Address - Fax:866-907-6157
Practice Address - Street 1:17885 NE EVERGREEN PARKWAY
Practice Address - Street 2:STE 220
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-571-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR65461225100000X
NY023017225100000X
WAPT00008783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7587LIOtherREGENCE
WA5479LIOtherREGENCE
WA7588LIOtherREGENCE
WA0219769OtherL&I
WA7588LIOtherREGENCE
WA4265LIOtherREGENCE
WA0210509OtherL&I
WAPTAN8867012Medicare PIN
WA0210509OtherL&I