Provider Demographics
NPI:1073587333
Name:SPISAK, ADA (CRNA)
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:
Last Name:SPISAK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:325 S BELMONT ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-2608
Practice Address - Country:US
Practice Address - Phone:717-843-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1349A367500000X
PARN250322L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC20882OtherCUMBERLAND HEALTHCARE INC
KYP00294276OtherRRMCR
PAP01312473OtherRAILROAD MEDICARE
KY74013491Medicaid
KY030670000OtherBLACK LUNG
KY000000378010OtherANTHEM PROVIDER #
PA214953VKCOtherNOVITAS MEDICARE
KY030670000OtherBLACK LUNG