Basic Information
| Provider Information | |||||||||
| NPI: | 1104836360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANZA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 PROVIDENCE DR | ||||||||
| Address2: | SUITE 207, PROVIDENCE ANCHORAGE ANESTHESIA MEDICAL GROU | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075610005 | ||||||||
| FaxNumber: | 9075639140 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 PROVIDENCE DR STE 207 | ||||||||
| Address2: | PROVIDENCE ANCHORAGE ANESTHESIA MEDICAL GROUP, P.C. | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075610005 | ||||||||
| FaxNumber: | 9075639140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 3907 | AK | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3907 | 05 | AK | MEDICAID | 300043459 | 05 | IN | MEDICAID | 7100699210 | 05 | KY | MEDICAID |