Provider Demographics
NPI:1629141544
Name:DESTEFANO, ED J (CRNA)
Entity Type:Individual
Prefix:
First Name:ED
Middle Name:J
Last Name:DESTEFANO
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 1:601 CHAPEL AVE E
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1454
Mailing Address - Country:US
Mailing Address - Phone:856-356-4025
Mailing Address - Fax:
Practice Address - Street 1:777 APPLETREE ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-1526
Practice Address - Country:US
Practice Address - Phone:856-356-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN259564L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered