Provider Demographics
NPI:1952596751
Name:DYNAMIC ANESTHESIA, PLLC
Entity Type:Organization
Organization Name:DYNAMIC ANESTHESIA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:DEFEO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, FNP-BC
Authorized Official - Phone:603-387-4523
Mailing Address - Street 1:1564 BROWNFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CENTER CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03813
Mailing Address - Country:US
Mailing Address - Phone:603-387-4523
Mailing Address - Fax:866-394-0351
Practice Address - Street 1:1564 BROWNFIELD RD
Practice Address - Street 2:
Practice Address - City:CENTER CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03813
Practice Address - Country:US
Practice Address - Phone:603-387-4523
Practice Address - Fax:866-394-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH047170-23-11174400000X
NH04717023-11367500000X
NH367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3079830Medicaid
NH0002890Medicare PIN
0002890Medicare PIN
NH3079830Medicaid
RE559301Medicare PIN