Provider Demographics
NPI:1306824917
Name:MASICA, LISA R (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:MASICA
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 1:2000 S MAYS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7580
Mailing Address - Country:US
Mailing Address - Phone:512-244-4272
Mailing Address - Fax:956-682-4154
Practice Address - Street 1:2000 S MAYS ST STE 201
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7580
Practice Address - Country:US
Practice Address - Phone:512-244-4272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX702173367500000X
TXAP113013367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008949441Medicaid
TX169583502Medicaid
TX00C40UOtherBCBS
TX169583513Medicaid
TX84100QOtherBCBS
TX169583501Medicaid
VA008949441Medicaid
TX84100QOtherBCBS
TX169583501Medicaid