Provider Demographics
NPI:1336695501
Name:VAN FOSSEN, MICHAEL JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:VAN FOSSEN
Suffix:JR
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:PO BOX 1568
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-7568
Mailing Address - Country:US
Mailing Address - Phone:856-829-3457
Mailing Address - Fax:
Practice Address - Street 1:435 HURFFVILLE CROSS KEYS RD
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2453
Practice Address - Country:US
Practice Address - Phone:856-582-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR14447600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered