Basic Information
| Provider Information | |||||||||
| NPI: | 1396730917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | LANORVELL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790058 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631790058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365492380 | ||||||||
| FaxNumber: | 3145695974 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 PROFESSIONAL CT | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217405826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404205559 | ||||||||
| FaxNumber: | 2404203786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 05/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R036279 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | KCB1CH | 01 | MD | CAREFIRST BCBS | OTHER | P00745079 | 01 | MD | MEDCIARE RAILROAD (GRP PTAN DD6120) | OTHER | P00811167 | 01 | MD | MEDICARE RAILROAD (GRP PTAN CJ8689) | OTHER | S417-0037 | 01 | DC | CAREFIRST BCBS | OTHER |