Provider Demographics
NPI:1972585792
Name:MAYO, REATA F (CRNA)
Entity Type:Individual
Prefix:
First Name:REATA
Middle Name:F
Last Name:MAYO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 ORTMAN RD
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-249-3999
Mailing Address - Fax:
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-3406
Practice Address - Fax:906-225-3094
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704128421367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430024327OtherRAILROAD MEDICARE PIN
MIRJ128421OtherBLUESHIELD PIN
MI103133127Medicaid
WI43400500OtherWISC MEDICAID PIN
MIE26018017Medicare PIN