Provider Demographics
NPI:1235106840
Name:PROVOST, LISA ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:PROVOST
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-376-1994
Practice Address - Fax:740-376-1940
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3485A367500000X
OHCOA.04992-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0069080000Medicaid
OH0282617Medicaid
KY74472408Medicaid
KY000000339679OtherANTHEM BLUE CROSS BLUE SHIELD
KYP00199967Medicare PIN
KYK173190Medicare PIN
KY000000339679OtherANTHEM BLUE CROSS BLUE SHIELD
KY74472408Medicaid