Healthcare Provider Details

I. General information

NPI: 1790749604
Provider Name (Legal Business Name): LISA G PEARSON DNAP, CRNA, NSPMC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LATIGO LANE SUITE D
CANON CITY CO
81212-8115
US

IV. Provider business mailing address

PO BOX 388
NEWTON KS
67114-0388
US

V. Phone/Fax

Practice location:
  • Phone: 719-371-0000
  • Fax:
Mailing address:
  • Phone: 316-281-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRXA-100001
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberAPN.0015078-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: