Provider Demographics
NPI:1790881621
Name:MCCORMICK DUPRE, PATRICIA M (CRNA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:MCCORMICK DUPRE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:M
Other - Last Name:DUPRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 714813
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271
Mailing Address - Country:US
Mailing Address - Phone:937-293-0247
Mailing Address - Fax:937-293-0960
Practice Address - Street 1:801 MEDICAL DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-4099
Practice Address - Country:US
Practice Address - Phone:419-224-7586
Practice Address - Fax:419-224-9769
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH037246367500000X
OHRN149531367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0583328OtherBCMH
OH2135684Medicaid
OH000000515999OtherANTHEM
OH037246OtherCRNA LICENSE
OH746241OtherBUCKEYE MEDICAID
OH000000226089OtherUNISON
OH414347OtherWELLCARE MEDICAID
7441733OtherAETNA
OH000000515999OtherANTHEM
7441733OtherAETNA