Provider Demographics
NPI:1790842961
Name:LONCHARICH, KOREEN S (CRNA)
Entity Type:Individual
Prefix:
First Name:KOREEN
Middle Name:S
Last Name:LONCHARICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KOREEN
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:11800 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3472
Mailing Address - Country:US
Mailing Address - Phone:586-573-5260
Mailing Address - Fax:586-573-5364
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5260
Practice Address - Fax:586-573-5364
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704135085367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2949430Medicaid
MIE06463029Medicare ID - Type Unspecified