Provider Demographics
NPI:1851393623
Name:DERAAD, GARY A (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:DERAAD
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 1:26699 MOHAWK DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5403
Mailing Address - Country:US
Mailing Address - Phone:419-690-7652
Mailing Address - Fax:419-697-7726
Practice Address - Street 1:2801 BAY PARK DR
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4920
Practice Address - Country:US
Practice Address - Phone:419-690-7652
Practice Address - Fax:419-697-7726
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4238A367500000X
OHRN 279724367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00619434OtherRRMC
000000556304OtherANTHEM
OH341881145-003OtherMMO
OH04097AOtherPARAMOUNT
MI5182096Medicaid
KY74007279Medicaid
KY0751616Medicare ID - Type Unspecified
KY74007279Medicaid