Provider Demographics
NPI:1104817485
Name:BOTT, LISA (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BOTT
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 1:2411 FOUNTAIN VIEW DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4832
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:
Practice Address - Street 1:2411 FOUNTAIN VIEW DR STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4832
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2767252367500000X
TX054363367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00702759OtherRAILROAD MEDICARE
TX87146UOtherBLUE CROSS BLUE SHIELD
TX188283902Medicaid
TX88597UOtherBLUE CROSS BLUE SHIELD
P00189829OtherRAILROAD MEDICARE
TXP00394592OtherMEDICARE RAILROAD
TX188283903Medicaid
FLG3214OtherBLUE CROSS BLUE SHIELD
TX87146UOtherBLUE CROSS BLUE SHIELD
TXTXB114105Medicare PIN
TXP00702759OtherRAILROAD MEDICARE
TX8K7171Medicare PIN
FLG3214Medicare ID - Type Unspecified