Provider Demographics
NPI:1568450435
Name:BAUER, LISA (CRNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BAUER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 JOHNSONBURG RD
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-3417
Mailing Address - Country:US
Mailing Address - Phone:724-349-8636
Mailing Address - Fax:
Practice Address - Street 1:753 JOHNSONBURG RD STE 150
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857
Practice Address - Country:US
Practice Address - Phone:724-349-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP003823B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA011516Medicare ID - Type Unspecified
PAS59511Medicare UPIN