Provider Demographics
NPI:1164519286
Name:OBERER, LISA G (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:OBERER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:J
Other - Last Name:GLASSFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2515
Mailing Address - Country:US
Mailing Address - Phone:704-384-4274
Mailing Address - Fax:704-384-5636
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-4274
Practice Address - Fax:704-384-5636
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2008-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN109922085R0202X
NC071172367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052930Medicaid
SCNAN779Medicaid
Q08240Medicare UPIN