1053663773 NPI number — LISA VERBOSH CRNA

Table of content: LISA VERBOSH CRNA (NPI 1053663773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053663773 NPI number — LISA VERBOSH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERBOSH
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZMIEJKO
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053663773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1245 S CEDAR CREST BLVD STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLENTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18103-6258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-402-8896
Provider Business Mailing Address Fax Number:
610-402-9029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1245 S CEDAR CREST BLVD STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18103-6258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-402-8896
Provider Business Practice Location Address Fax Number:
610-402-9029
Provider Enumeration Date:
10/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  91022 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1053663773 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1613617 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2745894 . This is a "FIRST PRIORITY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 9177918 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1027813210001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053663773 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 12447550 . This is a "CAQH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50111778 . This is a "CAPITAL ADVANTAGE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3888599000 . This is a "IND. BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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