Provider Demographics
NPI:1124292867
Name:LISA RANKIN MD PA
Entity type:Organization
Organization Name:LISA RANKIN MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RANKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:772-344-1409
Mailing Address - Street 1:499 NW PRIMA VISTA BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8786
Mailing Address - Country:US
Mailing Address - Phone:772-344-1409
Mailing Address - Fax:772-344-9441
Practice Address - Street 1:499 NW PRIMA VISTA BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8786
Practice Address - Country:US
Practice Address - Phone:772-344-1409
Practice Address - Fax:772-344-9441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0074325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253926800Medicaid
FLK5157Medicare PIN