Basic Information
Provider Information | |||||||||
NPI: | 1235106840 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PROVOST | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WALLACE | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 449 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | OH | ||||||||
PostalCode: | 457500449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403744500 | ||||||||
FaxNumber: | 7403745887 | ||||||||
Practice Location | |||||||||
Address1: | 401 MATTHEW ST | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | OH | ||||||||
PostalCode: | 457501635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403761994 | ||||||||
FaxNumber: | 7403761940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2006 | ||||||||
LastUpdateDate: | 12/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 3485A | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | COA.04992-NA | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 0069080000 | 05 | WV |   | MEDICAID | 0282617 | 05 | OH |   | MEDICAID | 74472408 | 05 | KY |   | MEDICAID | 000000339679 | 01 | KY | ANTHEM BLUE CROSS BLUE SHIELD | OTHER |