Provider Demographics
NPI:1033411566
Name:DEZA, ANICETTE PROTACIO (CRNA)
Entity Type:Individual
Prefix:
First Name:ANICETTE
Middle Name:PROTACIO
Last Name:DEZA
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 1:3131 SHOREWOOD PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3091
Mailing Address - Country:US
Mailing Address - Phone:804-763-6570
Mailing Address - Fax:
Practice Address - Street 1:10800 MIDLOTHIAN TPKE
Practice Address - Street 2:SUITE 265
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-4724
Practice Address - Country:US
Practice Address - Phone:804-594-2622
Practice Address - Fax:804-594-0915
Is Sole Proprietor?:No
Enumeration Date:2010-12-05
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001146339164W00000X
VA367A00000X367A00000X
VA0024169186367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ36291AMedicare PIN