Provider Demographics
NPI:1912056235
Name:STA MARIA, BERNADETTE S (CRNA)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:S
Last Name:STA MARIA
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 1:375 ENGLE STREET
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-871-6073
Mailing Address - Fax:201-655-6159
Practice Address - Street 1:350 ENGLE STREET
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631
Practice Address - Country:US
Practice Address - Phone:201-894-3322
Practice Address - Fax:201-894-0585
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY46838001367500000X
NJ26NR11075700367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00833003OtherRAILROAD MEDICARE
NJP00833003OtherRAILROAD MEDICARE
NJ129306Medicare PIN