Provider Demographics
NPI:1881637213
Name:HETRICK, LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:HETRICK
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 1:361 ALEXANDER SPRING
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-7696
Mailing Address - Country:US
Mailing Address - Phone:717-249-1212
Mailing Address - Fax:
Practice Address - Street 1:361 ALEXANDER SPRING RD.
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17015
Practice Address - Country:US
Practice Address - Phone:717-249-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN245215L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA038560Medicare ID - Type Unspecified
PAP08336Medicare UPIN