Provider Demographics
NPI:1508085358
Name:GORE, LISA E (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:GORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:E
Other - Last Name:GORE-SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:404 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6626
Practice Address - Country:US
Practice Address - Phone:573-875-9224
Practice Address - Fax:573-875-9284
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO124308367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO917307001Medicaid
MO787653OtherHEALTHLINK
MO127254OtherBLUE SHIELD
MO833765236Medicare PIN
MO787653OtherHEALTHLINK
MO833760635Medicare PIN