Basic Information
| Provider Information | |||||||||
| NPI: | 1740912054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYSAK | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 FIR STREET | ||||||||
| Address2: | |||||||||
| City: | SHERWOOD PARK | ||||||||
| State: | ALBERTA | ||||||||
| PostalCode: | T8A 2A4 | ||||||||
| CountryCode: | CA | ||||||||
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| Practice Location | |||||||||
| Address1: | 10121 PINE AVE | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961614856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305876011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2022 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 606606 | CA | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.