Healthcare Provider Details

I. General information

NPI: 1215274618
Provider Name (Legal Business Name): LISA C GANDER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 INDEPENDENCE BLVD STE 2G
VIRGINIA BEACH VA
23455-6010
US

IV. Provider business mailing address

816 INDEPENDENCE BLVD STE 2G
VIRGINIA BEACH VA
23455-6010
US

V. Phone/Fax

Practice location:
  • Phone: 757-363-6728
  • Fax: 757-363-6204
Mailing address:
  • Phone: 757-363-6728
  • Fax: 757-363-6204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number0024170563
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: