Provider Demographics
NPI:1538117130
Name:VANFOSSEN, MICA L (CRNA)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:L
Last Name:VANFOSSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MICA
Other - Middle Name:BOSO
Other - Last Name:VANFOSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:100 MEDICAL BLVD
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-9762
Mailing Address - Country:US
Mailing Address - Phone:412-359-6581
Mailing Address - Fax:412-359-3483
Practice Address - Street 1:500 LEWIS RUN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15122-3056
Practice Address - Country:US
Practice Address - Phone:412-469-6964
Practice Address - Fax:412-469-6948
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN307612L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA010060M5SMedicare ID - Type UnspecifiedPROVIDER NUMBER