Provider Demographics
NPI:1265666598
Name:LAKESIDE ANESTHESIA SERVICES
Entity Type:Organization
Organization Name:LAKESIDE ANESTHESIA SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:772-285-3457
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:SAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83860-0591
Mailing Address - Country:US
Mailing Address - Phone:208-265-3534
Mailing Address - Fax:208-265-3534
Practice Address - Street 1:520 N THIRD AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1507
Practice Address - Country:US
Practice Address - Phone:208-263-1441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-671367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDAPPLYINGOtherAPPLYING FOR ALL PROVIDER NUMBERS