Provider Demographics
NPI:1316942899
Name:LOUGHERY, LISA CLAIRE (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CLAIRE
Last Name:LOUGHERY
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:PO BOX 34672
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07189-0001
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:1140 ROUTE 72 W
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2412
Practice Address - Country:US
Practice Address - Phone:609-597-6011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR10190000367500000X
PARN227018L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50077111OtherCAPITAL BLUE CROSS, KEYSTONE CENTRAL, SENIOR BLUE
NJ046380RVBMedicare PIN
PA50077111OtherCAPITAL BLUE CROSS, KEYSTONE CENTRAL, SENIOR BLUE
PA018038GDNMedicare PIN
NJ046380CDYMedicare PIN
NJ046380CDZMedicare PIN
PA018038Q1RMedicare PIN
S63529Medicare UPIN
PA018038Medicare PIN
NJ046380A01Medicare PIN