Provider Demographics
NPI:1780646356
Name:PELISEK, SANDRA LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:PELISEK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LYNN
Other - Last Name:PERSINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-3076
Practice Address - Fax:864-455-4135
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH082454-23367500000X
FLARNP9163433367500000X
SC24723367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE3689TOtherMEDICARE - PTAN
FL305145500Medicaid
FLE3689TOtherMEDICARE - PTAN