Provider Demographics
NPI:1417965807
Name:WHITE, LISA A (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:DUBICKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3324 FRENCH PARK DR
Mailing Address - Street 2:STE D
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7269
Mailing Address - Country:US
Mailing Address - Phone:405-715-3610
Mailing Address - Fax:
Practice Address - Street 1:3324 FRENCH PARK DR
Practice Address - Street 2:STE B
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7269
Practice Address - Country:US
Practice Address - Phone:405-715-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK67714367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100782550AMedicaid