Healthcare Provider Details

I. General information

NPI: 1780674010
Provider Name (Legal Business Name): LISA A SEBASTIAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 POINTE WEST BLVD
BRADENTON FL
34209-5532
US

IV. Provider business mailing address

6015 POINTE WEST BLVD
BRADENTON FL
34209-5532
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-1404
  • Fax: 941-761-0712
Mailing address:
  • Phone: 941-792-1404
  • Fax: 941-761-0712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP3373072
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: