Provider Demographics
NPI:1669453478
Name:LYSENG, RITA ANN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:RITA
Middle Name:ANN
Last Name:LYSENG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:RITA
Other - Middle Name:ANN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 HOSPITAL PL
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7559
Mailing Address - Country:US
Mailing Address - Phone:907-714-4404
Mailing Address - Fax:
Practice Address - Street 1:250 HOSPITAL PL
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7559
Practice Address - Country:US
Practice Address - Phone:907-714-4404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK-CRNA #275367500000X
AKAK-RN #24570163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1030962Medicaid
AKK160964Medicare PIN