Basic Information
Provider Information | |||||||||
NPI: | 1740354513 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WUNDERLICH | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 847056 | ||||||||
Address2: | NASHUA ANESTHESIA PARTNERS | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022847056 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8007201664 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8 PROSPECT ST | ||||||||
Address2: | ANESTHESIA DEPT. | ||||||||
City: | NASHUA | ||||||||
State: | NH | ||||||||
PostalCode: | 030603925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6038892624 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 03/07/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 04007623-11 | NH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 30343405 | 05 | NH |   | MEDICAID |