Provider Demographics
NPI:1073581351
Name:MATHER, MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MATHER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DOMBKOWSKI
Other - Last Name:DISTASIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 947407
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:
Practice Address - Street 1:1700 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3509
Practice Address - Country:US
Practice Address - Phone:941-917-8720
Practice Address - Fax:941-917-1875
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2139842367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG1251OtherBCBS OF FLORIDA
FL009278100Medicaid
FL009278100Medicaid
FLG1251OtherBCBS OF FLORIDA
FLG1251NMedicare PIN