Provider Demographics
NPI:1780674010
Name:SEBASTIAN, LISA A (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 POINTE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5532
Mailing Address - Country:US
Mailing Address - Phone:941-792-1404
Mailing Address - Fax:941-761-0712
Practice Address - Street 1:6015 POINTE WEST BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5532
Practice Address - Country:US
Practice Address - Phone:941-792-1404
Practice Address - Fax:941-761-0712
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3373072367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG2483OtherBLUE CROSS BLUE SHIELD
FL310911900Medicaid
FLG2483OtherBLUE CROSS BLUE SHIELD