Provider Demographics
NPI:1104814516
Name:GRIZZARD, LANCE A (CRNA)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:A
Last Name:GRIZZARD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SPRING FOREST RD STE 130
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:888-280-9533
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:8260 ATLEE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1844
Practice Address - Country:US
Practice Address - Phone:804-288-6258
Practice Address - Fax:804-282-9921
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001154508163W00000X
VA0024166429367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010163188Medicaid
VA007027H90Medicare ID - Type Unspecified