Basic Information
| Provider Information | |||||||||
| NPI: | 1710955042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILETO | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2006 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704160785 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 5469 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2749045 | 05 | MI | MEDICAID | 430F364420 | 01 | MI | BCBSM | OTHER |