Provider Demographics
NPI:1316096985
Name:NYDAM, LISA ANN (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:NYDAM
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 1:7305 S PLATTE RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-2911
Mailing Address - Country:US
Mailing Address - Phone:925-830-8485
Mailing Address - Fax:
Practice Address - Street 1:1001 SOUTHPARK DR
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-5641
Practice Address - Country:US
Practice Address - Phone:303-722-8789
Practice Address - Fax:303-722-2935
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3217367500000X
COAPN.0991047-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ40124Medicare UPIN
CO337112YPYWMedicare PIN