Provider Demographics
NPI:1598007825
Name:BACKENSTOE, CODY OWEN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:OWEN
Last Name:BACKENSTOE
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 1:4653 STEVEN LN
Mailing Address - Street 2:
Mailing Address - City:WALNUTPORT
Mailing Address - State:PA
Mailing Address - Zip Code:18088-9619
Mailing Address - Country:US
Mailing Address - Phone:484-951-3582
Mailing Address - Fax:
Practice Address - Street 1:421 CHEW ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102-3406
Practice Address - Country:US
Practice Address - Phone:610-776-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN595267367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered