Provider Demographics
NPI:1992167191
Name:LISTER, ANDREW (DO)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:LISTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8570 GRANITE CT STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4102
Mailing Address - Country:US
Mailing Address - Phone:239-310-4646
Mailing Address - Fax:
Practice Address - Street 1:8570 GRANITE CT STE 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4102
Practice Address - Country:US
Practice Address - Phone:239-310-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-26
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS160852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry