Provider Demographics
NPI:1952353294
Name:HERMAN, THADDEUS (CRNA)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:
Last Name:HERMAN
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 1:968 PARADROME ST APT A
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-6038
Mailing Address - Country:US
Mailing Address - Phone:574-596-9686
Mailing Address - Fax:
Practice Address - Street 1:6225 STATE HWY 161 STE 200
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2241
Practice Address - Country:US
Practice Address - Phone:214-687-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CRNA.019435367500000X
IN28155396367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200431170Medicaid