Provider Demographics
NPI:1164594669
Name:DREDLA, THOMAS J III (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:DREDLA
Suffix:III
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 1:4021 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4602
Mailing Address - Country:US
Mailing Address - Phone:308-641-1311
Mailing Address - Fax:308-630-1656
Practice Address - Street 1:4021 AVENUE B
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4602
Practice Address - Country:US
Practice Address - Phone:308-641-1311
Practice Address - Fax:308-630-1656
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100028367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE279888Medicare ID - Type Unspecified
NER30273Medicare UPIN