Provider Demographics
NPI:1023031127
Name:LYSINGER, WALTER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:
Last Name:LYSINGER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 GABRIEL AVE
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95993-8625
Mailing Address - Country:US
Mailing Address - Phone:530-673-2653
Mailing Address - Fax:530-673-2653
Practice Address - Street 1:591 GABRIEL AVE
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993-8625
Practice Address - Country:US
Practice Address - Phone:530-673-2653
Practice Address - Fax:530-673-2653
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN3187510207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN3187510Medicaid
CAZZZ16781Z 13OtherBLUE SHIELD
CAZZZ16781Z 13OtherBLUE SHIELD