Provider Demographics
NPI:1972618098
Name:THOMPSON, KISHA N (CRNA)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:N
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KISHA
Other - Middle Name:N
Other - Last Name:LIFGREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2907
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:45 READE PL
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3947
Practice Address - Country:US
Practice Address - Phone:845-431-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY505994 1367500000X
NH074874-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR42R22Y421Medicare PIN