Provider Demographics
NPI:1992764849
Name:TICHENOR, LISA ASHLEY (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ASHLEY
Last Name:TICHENOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8390 CHAMPIONS GATE BOULEVARD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896
Mailing Address - Country:US
Mailing Address - Phone:407-390-1677
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:5731 BEE RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233
Practice Address - Country:US
Practice Address - Phone:941-342-1100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7661207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56739OtherBCBS
G51488Medicare UPIN
FL56739OtherBCBS