Basic Information
| Provider Information | |||||||||
| NPI: | 1053663773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VERBOSH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZMIEJKO | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1245 S CEDAR CREST BLVD STE 301 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104028896 | ||||||||
| FaxNumber: | 6104029029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 S CEDAR CREST BLVD STE 301 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104028896 | ||||||||
| FaxNumber: | 6104029029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2012 | ||||||||
| LastUpdateDate: | 04/07/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 91022 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1053663773 | 01 | PA | GEISINGER | OTHER | 1613617 | 01 | PA | GATEWAY | OTHER | 2745894 | 01 | PA | FIRST PRIORITY | OTHER | 9177918 | 01 | PA | AETNA | OTHER | 1027813210001 | 05 | PA | MEDICAID | 1053663773 | 01 | PA | HIGHMARK | OTHER | 12447550 | 01 | PA | CAQH | OTHER | 50111778 | 01 | PA | CAPITAL ADVANTAGE | OTHER | 3888599000 | 01 | PA | IND. BLUE CROSS | OTHER |