1760821383 NPI number — PETRA W. HARDEN CRNA

Table of content: PETRA W. HARDEN CRNA (NPI 1760821383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760821383 NPI number — PETRA W. HARDEN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARDEN
Provider First Name:
PETRA
Provider Middle Name:
W.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VICKNAIR
Provider Other First Name:
PETRA
Provider Other Middle Name:
W.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760821383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4918
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32802-4918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-581-9180
Provider Business Mailing Address Fax Number:
407-926-9173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 E ROBINSON ST
Provider Second Line Business Practice Location Address:
SUITE #130
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32801-4322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-581-9180
Provider Business Practice Location Address Fax Number:
407-926-9173
Provider Enumeration Date:
06/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  ARNP9233868 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009489100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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