Basic Information
| Provider Information | |||||||||
| NPI: | 1841282134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROOT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 LARK ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376048218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232830776 | ||||||||
| FaxNumber: | 4239685697 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 MED TECH PKWY | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236101020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN0000114257 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3625581 | 05 | TN | MEDICAID |