Provider Demographics
NPI:1407829062
Name:DIFFENDERFFER, PAUL J (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:DIFFENDERFFER
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 1:401 S BALLENGER HWY
Mailing Address - Street 2:ATTN SURGICAL SERVICES
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:840-342-4917
Mailing Address - Fax:810-342-1335
Practice Address - Street 1:401 S BALLENGER HWY
Practice Address - Street 2:ATTN SURGICAL SERVICES
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3638
Practice Address - Country:US
Practice Address - Phone:840-342-4917
Practice Address - Fax:810-342-1335
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704112417367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPD112417OtherBLUE SHIELD
MI1599758Medicaid