Provider Demographics
NPI:1174358360
Name:SISIC, LEA (PA)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:SISIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34041 US 19 N STE D
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-2648
Mailing Address - Country:US
Mailing Address - Phone:727-942-5189
Mailing Address - Fax:727-390-8309
Practice Address - Street 1:34041 US 19 N STE D
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-2648
Practice Address - Country:US
Practice Address - Phone:727-942-5189
Practice Address - Fax:727-390-8309
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119448363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant