Provider Demographics
NPI:1316991433
Name:BLAIR, LISA JENNIFER (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JENNIFER
Last Name:BLAIR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JENNIFER
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1074
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34697-1074
Mailing Address - Country:US
Mailing Address - Phone:727-376-3065
Mailing Address - Fax:
Practice Address - Street 1:601 MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-5848
Practice Address - Country:US
Practice Address - Phone:727-734-6916
Practice Address - Fax:727-734-4516
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR26329367500000X
WVAPRN102078367500000X
FLARNP9166030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3955OtherBCBS OF FLORIDA
FLU7062AMedicare ID - Type Unspecified