Provider Demographics
NPI:1518251503
Name:SISAM, ERIC E (APRN, CRNA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:E
Last Name:SISAM
Suffix:
Gender:M
Credentials:APRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3696 CHESAPEAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-4350
Mailing Address - Country:US
Mailing Address - Phone:203-450-7247
Mailing Address - Fax:
Practice Address - Street 1:1200 W MOHAVE RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-6349
Practice Address - Country:US
Practice Address - Phone:928-669-9201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01404367500000X
AZCRNA1126367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered