Provider Demographics
NPI:1720299779
Name:CHADERJIAN, LISA A (APRN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:CHADERJIAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 SEYMOUR ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06102-8000
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:3500 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1137
Practice Address - Country:US
Practice Address - Phone:413-794-0900
Practice Address - Fax:413-794-2996
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3282363LA2200X
MARN213855363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ53820Medicare UPIN
CT004032827Medicaid
CT500002005 (C00814)Medicare PIN