Provider Demographics
NPI:1508154592
Name:MAZZELLA, DANIEL CHRISTOPHER (CRNA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:CHRISTOPHER
Last Name:MAZZELLA
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 1:110 ROANE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2334
Mailing Address - Country:US
Mailing Address - Phone:304-344-0096
Mailing Address - Fax:304-342-4725
Practice Address - Street 1:333 LAIDLEY ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1614
Practice Address - Country:US
Practice Address - Phone:304-347-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV48555163W00000X
WV085360367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021321Medicaid
WVQ37026AOtherMEDICARE PTAN
WVP00981780OtherMEDICARE RAILROAD