Provider Demographics
NPI:1326739343
Name:LUNGAY, MARA (CRNA)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:LUNGAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:
Other - Last Name:KUBISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 28900
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54324-0900
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1102959367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered