Provider Demographics
NPI:1891740445
Name:REARICK, MICHAEL MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MARK
Last Name:REARICK
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 1:759 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-1127
Mailing Address - Country:US
Mailing Address - Phone:540-459-1287
Mailing Address - Fax:540-459-1293
Practice Address - Street 1:1000 N SHENANDOAH AVE
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-3547
Practice Address - Country:US
Practice Address - Phone:540-636-0296
Practice Address - Fax:540-636-0258
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024137990367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA103143Medicare PIN
VA017227W82Medicare PIN