Provider Demographics
NPI:1043288319
Name:HARTLEY, DEBORAH A (CRNA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:HARTLEY
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 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3630
Practice Address - Street 1:901 MT VIEW DR
Practice Address - Street 2:BUILDING 1
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4401
Practice Address - Country:US
Practice Address - Phone:360-426-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00094991367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9619263Medicaid
WA126457155OtherTRICARE
WAHA6715OtherBLUE CROSS OF WA
WAGAB09010Medicare ID - Type Unspecified
WA9619263Medicaid