Provider Demographics
NPI:1982613014
Name:MCCLOY, LISA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MCCLOY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:101 STADIUM DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-7911
Practice Address - Country:US
Practice Address - Phone:304-598-4000
Practice Address - Fax:304-293-6963
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV47628367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006674Medicaid
WVP00354769OtherRAILROAD MEDICARE
WVOL6034971Medicare PIN