Provider Demographics
NPI:1083693113
Name:LUSTRE NOSAL, MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LUSTRE NOSAL
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 1:285 ANGOLA ST
Mailing Address - Street 2:
Mailing Address - City:WOLVERINE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2113
Mailing Address - Country:US
Mailing Address - Phone:248-767-7871
Mailing Address - Fax:
Practice Address - Street 1:1447 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4727
Practice Address - Country:US
Practice Address - Phone:989-583-6237
Practice Address - Fax:989-583-6032
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704149936367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIML149936OtherBLUE CROSS OF MI
MI104299871Medicaid
MIML149936OtherBLUE CROSS OF MI
MI430062960Medicare ID - Type UnspecifiedRAILROAD MEDICARE