Provider Demographics
NPI:1437399953
Name:DISANDRO, NICOLA D (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:D
Last Name:DISANDRO
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 1:255 W MICHIGAN AVE
Mailing Address - Street 2:PO BOX 1123
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:5039 SWAMP RD
Practice Address - Street 2:406
Practice Address - City:FOUNTAINVILLE
Practice Address - State:PA
Practice Address - Zip Code:18923-9667
Practice Address - Country:US
Practice Address - Phone:215-348-1523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN535251367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered