Provider Demographics
NPI:1063485241
Name:COLYER, GWENDOLYN LEIGH (CRNA)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:LEIGH
Last Name:COLYER
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 1:2749 PIN OAK DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-1862
Mailing Address - Country:US
Mailing Address - Phone:419-841-0659
Mailing Address - Fax:
Practice Address - Street 1:5901 MONCLOVA RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1855
Practice Address - Country:US
Practice Address - Phone:419-897-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCOA.08219-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2559299Medicaid
OH8235111Medicare PIN
P00240831Medicare PIN