Provider Demographics
NPI:1467575894
Name:SHAMBO, LYDA A (CRNA)
Entity Type:Individual
Prefix:DR
First Name:LYDA
Middle Name:A
Last Name:SHAMBO
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 1:420 CENTRAL PARK W
Mailing Address - Street 2:APT. 4G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4375
Mailing Address - Country:US
Mailing Address - Phone:917-455-3722
Mailing Address - Fax:
Practice Address - Street 1:420 CENTRAL PARK W
Practice Address - Street 2:APT. 4G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4375
Practice Address - Country:US
Practice Address - Phone:917-455-3722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001204398163W00000X
NY525267163W00000X, 367500000X
VA0024167441367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4024Medicaid