Provider Demographics
NPI:1790753226
Name:HORNE, MICHAEL A (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:HORNE
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 1:352 CLEARWATER DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4169
Mailing Address - Country:US
Mailing Address - Phone:904-403-1667
Mailing Address - Fax:904-280-0051
Practice Address - Street 1:352 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4169
Practice Address - Country:US
Practice Address - Phone:904-403-1667
Practice Address - Fax:904-280-0051
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9164272367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304294400Medicaid
FLG2977ZMedicare ID - Type Unspecified