Provider Demographics
NPI:1699914044
Name:LISH, DEREK C (CRNA)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:C
Last Name:LISH
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:PO BOX 4268
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4268
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-373-2754
Practice Address - Street 1:950 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4724
Practice Address - Country:US
Practice Address - Phone:435-734-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTEMP RNA 19861367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1605349Medicare PIN