Provider Demographics
NPI:1467425306
Name:STUCKEY, LARRY D (CRNA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:STUCKEY
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 1:600 ONE STRAIGHT DR
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-8845
Mailing Address - Country:US
Mailing Address - Phone:419-229-2622
Mailing Address - Fax:419-229-2646
Practice Address - Street 1:2740 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3216
Practice Address - Country:US
Practice Address - Phone:419-693-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.02581-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0758309Medicaid
MI4704165719OtherMI LICENSE
OH8203977Medicare PIN
MI4704165719OtherMI LICENSE