Provider Demographics
NPI:1639409394
Name:GISH, DEANNA MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:MARY
Last Name:GISH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:MARY
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2829
Practice Address - Fax:417-820-8852
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCTP-000120367500000X
MO2011040587367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01059535OtherMCR - RR
MO431560263OtherTRICARE
MO1639409394Medicaid
AR185881001Medicaid
MO1639409394Medicaid