Provider Demographics
NPI:1679951438
Name:ANTONIO, LISA MARIE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 CHANNEL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7837
Mailing Address - Country:US
Mailing Address - Phone:907-463-4074
Mailing Address - Fax:907-463-1510
Practice Address - Street 1:222 TONGASS DR
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835
Practice Address - Country:US
Practice Address - Phone:907-966-8318
Practice Address - Fax:907-966-8606
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-RES-LIC 52169390200000X
AK134059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK134059OtherSTATE LICENSE