Provider Demographics
NPI:1033103874
Name:PRYDE, CHRISTINA DALTON (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:DALTON
Last Name:PRYDE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:L
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 PARK FOREST DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7331
Mailing Address - Country:US
Mailing Address - Phone:231-935-5770
Mailing Address - Fax:231-935-0747
Practice Address - Street 1:4100 PARK FOREST DR
Practice Address - Street 2:SUITE 210
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7331
Practice Address - Country:US
Practice Address - Phone:231-935-5770
Practice Address - Fax:231-935-0747
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704182721367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1033103874Medicaid
0B86029 017Medicare PIN
P28015Medicare UPIN