Provider Demographics
NPI:1952345035
Name:SLATTERY, MICHAEL J (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SLATTERY
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 1:602 PARMALEE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44510-1653
Mailing Address - Country:US
Mailing Address - Phone:330-742-2100
Mailing Address - Fax:330-742-2107
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-742-2100
Practice Address - Fax:330-742-2107
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN169206367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH883567Medicaid
OH883567Medicaid