Provider Demographics
NPI:1609315969
Name:AMUNDSON, RICHARD M (CRNA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:AMUNDSON
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 1:512 BROMLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14428-9610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 PINE GROVE CMNS
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5151
Practice Address - Country:US
Practice Address - Phone:717-741-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY644378-1163W00000X
PATLRN050941367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse