Provider Demographics
NPI:1003812819
Name:DAVIS, DEIRDRE A (CRNA)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:A
Last Name:DAVIS
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 307
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07754-0307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:732-897-0263
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
Practice Address - Country:US
Practice Address - Phone:609-597-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY356194174400000X
NY356194-1367500000X
NJ26NJ00224100367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR1B561Medicare ID - Type Unspecified
NJ150786Medicare PIN