Healthcare Provider Details

I. General information

NPI: 1740683150
Provider Name (Legal Business Name): LISA PIPOSAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

IV. Provider business mailing address

365 MONTAUK AVE APT 2A
NEW LONDON CT
06320-4700
US

V. Phone/Fax

Practice location:
  • Phone: 860-444-5117
  • Fax:
Mailing address:
  • Phone: 860-444-5117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number104412
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: