Provider Demographics
NPI:1184642043
Name:MARRA, JAMES (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MARRA
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 1:156 CORLISS AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2060
Mailing Address - Country:US
Mailing Address - Phone:607-763-6735
Mailing Address - Fax:
Practice Address - Street 1:156 CORLISS AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2060
Practice Address - Country:US
Practice Address - Phone:607-763-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5325892367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA6761Medicare PIN