Provider Demographics
NPI:1881822039
Name:RETZLOFF, JOHN J (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:RETZLOFF
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:PO BOX 3055
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3055
Mailing Address - Country:US
Mailing Address - Phone:317-567-2180
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:500 N NAPPANEE ST
Practice Address - Street 2:SUITE 11B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1503
Practice Address - Country:US
Practice Address - Phone:574-522-9922
Practice Address - Fax:574-522-9926
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28146650A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered