Provider Demographics
NPI:1124218110
Name:ST PAUL, IRENE A (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:A
Last Name:ST PAUL
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 1:4814 WILLES VISION DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4671
Mailing Address - Country:US
Mailing Address - Phone:973-666-1404
Mailing Address - Fax:
Practice Address - Street 1:4814 WILLES VISION DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4671
Practice Address - Country:US
Practice Address - Phone:973-666-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE0001405282N00000X
CT3808367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE510069243Medicare Oscar/Certification