Provider Demographics
NPI:1790767853
Name:BENDER, KATHRYN S (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:S
Last Name:BENDER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W KAYE AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2614
Mailing Address - Country:US
Mailing Address - Phone:906-226-8511
Mailing Address - Fax:
Practice Address - Street 1:901 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-1367
Practice Address - Country:US
Practice Address - Phone:906-486-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704157469367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104654138Medicaid
WI44337700OtherWISC MEDICAID PIN
MIKB157469OtherBLUESHIELD PIN
MIKB157469OtherBLUESHIELD PIN