Provider Demographics
NPI:1669650693
Name:MATTAMANA, GEORGE KORAH (CRNA)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:KORAH
Last Name:MATTAMANA
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 1:1655 ASHMONT CT
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-7060
Mailing Address - Country:US
Mailing Address - Phone:937-829-9033
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:88MDG/SGHJ
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5546
Practice Address - Country:US
Practice Address - Phone:937-829-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2013-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005020681163W00000X
OHCOA.10047-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse