Provider Demographics
NPI:1558693499
Name:DEETER, MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DEETER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-226-5018
Mailing Address - Fax:419-998-4514
Practice Address - Street 1:1001 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2800
Practice Address - Country:US
Practice Address - Phone:419-228-3335
Practice Address - Fax:419-998-4514
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.11329-NA367500000X
OHNA11329367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3031954Medicaid
OH8246472Medicare PIN
OH3031954Medicaid