Provider Demographics
NPI:1396730917
Name:ROBERTSON, LANORVELL (CRNA)
Entity type:Individual
Prefix:
First Name:LANORVELL
Middle Name:
Last Name:ROBERTSON
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:PO BOX 790058
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-0058
Mailing Address - Country:US
Mailing Address - Phone:636-549-2380
Mailing Address - Fax:314-569-5974
Practice Address - Street 1:1110 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5826
Practice Address - Country:US
Practice Address - Phone:240-420-5559
Practice Address - Fax:240-420-3786
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR036279367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKCB1CHOtherCAREFIRST BCBS
MDP00745079OtherMEDCIARE RAILROAD (GRP PTAN DD6120)
MDP00811167OtherMEDICARE RAILROAD (GRP PTAN CJ8689)
DCS417-0037OtherCAREFIRST BCBS
DCS417-0037OtherCAREFIRST BCBS