Provider Demographics
NPI:1790399343
Name:MITZELFELT, EDWARD WILLIAM (CRNA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:WILLIAM
Last Name:MITZELFELT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:35846 PLUMERIA WAY
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-2660
Mailing Address - Country:US
Mailing Address - Phone:309-241-8851
Mailing Address - Fax:
Practice Address - Street 1:250 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1103
Practice Address - Country:US
Practice Address - Phone:408-972-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021446367500000X
CA95001420367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered