Provider Demographics
NPI:1912083379
Name:MOERSDORF, LUCAS JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:JOHN
Last Name:MOERSDORF
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 5059
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37831-5059
Mailing Address - Country:US
Mailing Address - Phone:919-858-6303
Mailing Address - Fax:770-237-1124
Practice Address - Street 1:990 OAK RIDGE TURNPIKE
Practice Address - Street 2:MMC ANESTHESIA PC
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6976
Practice Address - Country:US
Practice Address - Phone:919-858-6303
Practice Address - Fax:770-237-1124
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN136698163W00000X
TN12486367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN136698OtherRN LICENSURE