Provider Demographics
NPI:1275678468
Name:DEMASK, DAVID ROY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ROY
Last Name:DEMASK
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 1:501 GOPHER DR
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-4513
Mailing Address - Country:US
Mailing Address - Phone:083-722-1816
Mailing Address - Fax:
Practice Address - Street 1:501 GOPHER DR
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-4513
Practice Address - Country:US
Practice Address - Phone:608-372-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI264367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI264OtherLICENSE NUMBER
WI43290200Medicaid
WI21440Medicare ID - Type UnspecifiedMEDICARE NUMBER
WI43290200Medicaid