Provider Demographics
NPI:1659792166
Name:LUM, ANDY (CRNA RN)
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:LUM
Suffix:
Gender:M
Credentials:CRNA RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 NAUTICAL WAVES RD
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-4678
Mailing Address - Country:US
Mailing Address - Phone:757-650-9453
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD BLDG 100
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:757-650-9453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC006846367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered