Provider Demographics
NPI:1154353928
Name:CARLISLE, MARY A (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:CAREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:211 OAK WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2523
Mailing Address - Country:US
Mailing Address - Phone:310-600-9698
Mailing Address - Fax:
Practice Address - Street 1:250 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1103
Practice Address - Country:US
Practice Address - Phone:408-972-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA3278367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWNA3278AMedicare ID - Type Unspecified