Provider Demographics
NPI:1578547337
Name:ERTL, GARY D (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:ERTL
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 1:2817 NEW PINERY RD
Mailing Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9240
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:608-742-6098
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9240
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:608-742-6098
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57794030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43302200Medicaid
WI43302200Medicaid