Provider Demographics
NPI:1033484548
Name:BROWN, DEFOREST ROCHE (CRNA)
Entity Type:Individual
Prefix:
First Name:DEFOREST
Middle Name:ROCHE
Last Name:BROWN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:740-348-4226
Mailing Address - Fax:740-348-4217
Practice Address - Street 1:1320 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055
Practice Address - Country:US
Practice Address - Phone:740-348-4226
Practice Address - Fax:740-348-4217
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH250550367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN430007762Medicare PIN