Provider Demographics
NPI:1831499920
Name:LYSTRUP, PAUL DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:LYSTRUP
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 HAMMOCKS DR
Mailing Address - Street 2:APT 308
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-4260
Mailing Address - Country:US
Mailing Address - Phone:623-466-3387
Mailing Address - Fax:
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-24
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 636868163W00000X
NY636868367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse