Provider Demographics
NPI:1861613119
Name:ANDERSON, LYZA J (CRNA)
Entity type:Individual
Prefix:
First Name:LYZA
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 TROON RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2836
Mailing Address - Country:US
Mailing Address - Phone:404-918-9019
Mailing Address - Fax:
Practice Address - Street 1:242 9TH AVENUE DR NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3828
Practice Address - Country:US
Practice Address - Phone:828-322-7305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN144880367500000X
OR201508616CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA082191424AOtherPEACHSTATE CMO- MCCG
GA082191424AMedicaid
GA344382OtherWELLCARE CMO - MCCG
GAP00088939OtherRAILROAD MCR - MCCG
Q08500Medicare UPIN
GA344382OtherWELLCARE CMO - MCCG