Provider Demographics
NPI:1811475494
Name:SPATARO, MICHAEL ANTHONY (RN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:SPATARO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3226 OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-1030
Mailing Address - Country:US
Mailing Address - Phone:440-865-5537
Mailing Address - Fax:
Practice Address - Street 1:3226 OAKDALE AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055
Practice Address - Country:US
Practice Address - Phone:440-865-5537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-05
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.166363.MEDS-IV164W00000X
OHRN.499852163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH104987202999Medicaid