Provider Demographics
NPI:1255609962
Name:WATZEK, MICHAEL A (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:WATZEK
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 1:6917 SHAMROCK AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-5533
Mailing Address - Country:US
Mailing Address - Phone:513-833-1506
Mailing Address - Fax:
Practice Address - Street 1:4777 E GALBRAITH RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2725
Practice Address - Country:US
Practice Address - Phone:513-686-5093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-255274163W00000X
OH86775367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse