Provider Demographics
NPI:1982691325
Name:COLES, LISA (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COLES
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 1:5 HAWTHORNE CT
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-4303
Mailing Address - Country:US
Mailing Address - Phone:484-390-3833
Mailing Address - Fax:
Practice Address - Street 1:2301 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3542
Practice Address - Country:US
Practice Address - Phone:215-952-9323
Practice Address - Fax:215-952-1246
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN276938L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019764970002Medicaid
PAS55631Medicare UPIN
PA008020Medicare PIN