=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336561356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WAYNE LISAK II CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2014
-----------------------------------------------------
Last Update Date | 07/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 W 13 MILE RD ANESTHESIA
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48073-6712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-898-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 750 STEPHENSON HWY BEAUMONT PAYOR CONTRACT SERVICES
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48083-1103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-577-3511
-----------------------------------------------------
Fax | 248-577-3526
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 4704272201
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------