Provider Demographics
NPI:1497337463
Name:VONALLMAN, DERECK (CRNA)
Entity Type:Individual
Prefix:
First Name:DERECK
Middle Name:
Last Name:VONALLMAN
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 1:592 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2884
Mailing Address - Country:US
Mailing Address - Phone:330-749-5731
Mailing Address - Fax:
Practice Address - Street 1:592 STEWART AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-2884
Practice Address - Country:US
Practice Address - Phone:330-749-5731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.396668163W00000X
OHAPRN.CRNA.0020316367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH163W00000XMedicaid