Provider Demographics
NPI:1790749604
Name:PEARSON, LISA G (DNAP, CRNA, NSPMC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:PEARSON
Suffix:
Gender:F
Credentials:DNAP, CRNA, NSPMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-0388
Mailing Address - Country:US
Mailing Address - Phone:316-281-3700
Mailing Address - Fax:
Practice Address - Street 1:113 LATIGO LANE
Practice Address - Street 2:SUITE D
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-8115
Practice Address - Country:US
Practice Address - Phone:719-371-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORXA-100001367500000X
COAPN.0015078-CRNA208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
144964Medicare ID - Type Unspecified