Provider Demographics
NPI:1144217316
Name:YEDLOCK, RAYMOND A (CRNA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
Last Name:YEDLOCK
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 1:1245 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE #301
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6258
Mailing Address - Country:US
Mailing Address - Phone:610-402-9099
Mailing Address - Fax:610-402-9029
Practice Address - Street 1:17TH & CHEW STREET
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102
Practice Address - Country:US
Practice Address - Phone:610-402-9099
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN269524L163W00000X
PA040438367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1345054OtherHIGHMARK
PA2037613000OtherINDEP. BLUE CROSS
PA03226201OtherCAPITAL ADVANTAGE
PA1027812230001Medicaid
PA1585282OtherGATEWAY
PA9358458OtherAETNA
PA1345054OtherFIRST PRIORITY
PA11783713OtherCAQH
PA1345054OtherKHP CENTRAL
PA72366OtherGEISINGER
PA1027812230001Medicaid
PA11783713OtherCAQH
PAS48788Medicare UPIN