Provider Demographics
NPI:1376629907
Name:REIDINGER, CHARLES ALEC (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALEC
Last Name:REIDINGER
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:PO BOX 438
Mailing Address - Street 2:800 ALDER STREET
Mailing Address - City:SOUTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98586
Mailing Address - Country:US
Mailing Address - Phone:360-875-5526
Mailing Address - Fax:360-875-6167
Practice Address - Street 1:800 ALDER STREET
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98586
Practice Address - Country:US
Practice Address - Phone:360-875-5526
Practice Address - Fax:360-875-6167
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002153367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9620337Medicaid
R80186Medicare UPIN
AB3795Medicare ID - Type Unspecified