Provider Demographics
NPI:1043631674
Name:SMITH, LISA A (CRNA,DMPNA,APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA,DMPNA,APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST
Mailing Address - Street 2:WALLER BUILDING, SUITE B06
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2677
Mailing Address - Country:US
Mailing Address - Phone:740-356-8008
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2640
Practice Address - Country:US
Practice Address - Phone:740-356-8681
Practice Address - Fax:740-353-7900
Is Sole Proprietor?:No
Enumeration Date:2013-12-27
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41794367500000X
KY3008483367500000X
OHCOA.15927-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered