Provider Demographics
NPI:1962808899
Name:LISTER, PATRICK MICHAEL JR (PTA)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:MICHAEL
Last Name:LISTER
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 HOFFER ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17057-2836
Mailing Address - Country:US
Mailing Address - Phone:717-574-3412
Mailing Address - Fax:
Practice Address - Street 1:649 HOFFER ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:PA
Practice Address - Zip Code:17057-2836
Practice Address - Country:US
Practice Address - Phone:717-574-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI003819225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant