Provider Demographics
NPI:1821523986
Name:DIVELL, ERIC (CRNA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:DIVELL
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 1:4606 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-1451
Mailing Address - Country:US
Mailing Address - Phone:814-449-5752
Mailing Address - Fax:
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-2621
Practice Address - Fax:814-877-7049
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN641349163W00000X, 367500000X
NY695200-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse