Provider Demographics
NPI:1861425548
Name:FERGUSON, LISA MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:GENOVESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:7101 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3701
Mailing Address - Country:US
Mailing Address - Phone:561-515-1500
Mailing Address - Fax:
Practice Address - Street 1:7101 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3701
Practice Address - Country:US
Practice Address - Phone:561-515-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9167524367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG4065OtherBCBS OF FLORIDA
FL307786100Medicaid
FL307786100Medicaid