Provider Demographics
NPI:1083317218
Name:KAST, CHARISSA ANN MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:ANN MARIE
Last Name:KAST
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CHARISSA
Other - Middle Name:
Other - Last Name:GOOSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:25288 VAN LEUVEN ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2212
Mailing Address - Country:US
Mailing Address - Phone:813-504-6550
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95167170163WC0200X
CA95002048367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine