Provider Demographics
NPI:1649252354
Name:FULTON MARGIEWICZ, JUNE A (CRNA)
Entity type:Individual
Prefix:MRS
First Name:JUNE
Middle Name:A
Last Name:FULTON MARGIEWICZ
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 1:600 RANCH RD
Mailing Address - Street 2:
Mailing Address - City:REEDSPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97467-1720
Mailing Address - Country:US
Mailing Address - Phone:541-271-2171
Mailing Address - Fax:
Practice Address - Street 1:600 RANCH RD
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467-1795
Practice Address - Country:US
Practice Address - Phone:541-271-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN10709367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3624253Medicaid
TN3624253Medicaid