Provider Demographics
NPI:1457345035
Name:BACKENSTOE, JOAN ELYSE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:ELYSE
Last Name:BACKENSTOE
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 1:4653 STEVEN LN
Mailing Address - Street 2:
Mailing Address - City:WALNUTPORT
Mailing Address - State:PA
Mailing Address - Zip Code:18088-9619
Mailing Address - Country:US
Mailing Address - Phone:610-767-3476
Mailing Address - Fax:
Practice Address - Street 1:3147 COLLEGE HEIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-4813
Practice Address - Country:US
Practice Address - Phone:610-841-2432
Practice Address - Fax:610-841-4433
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN184932L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00456743OtherRAILROAD MEDICARE
PA1466649OtherHIGHMARK
PA20035314OtherAMERIHEALTH MERCY
PA0016767680004Medicaid
PA1466649OtherHIGHMARK
S46825Medicare UPIN
004120Medicare ID - Type Unspecified