Basic Information
Provider Information | |||||||||
NPI: | 1669453478 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LYSENG | ||||||||
FirstName: | RITA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PHILLIPS | ||||||||
OtherFirstName: | RITA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 250 HOSPITAL PL | ||||||||
Address2: |   | ||||||||
City: | SOLDOTNA | ||||||||
State: | AK | ||||||||
PostalCode: | 996697559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9077144404 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 250 HOSPITAL PL | ||||||||
Address2: |   | ||||||||
City: | SOLDOTNA | ||||||||
State: | AK | ||||||||
PostalCode: | 996697559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9077144404 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2005 | ||||||||
LastUpdateDate: | 10/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AK-CRNA #275 | AK | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 163W00000X | AK-RN #24570 | AK | Y |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 1030962 | 05 | AK |   | MEDICAID |