Healthcare Provider Details

I. General information

NPI: 1356446397
Provider Name (Legal Business Name): MICHAELA LONG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST
FAIRBANKS AK
99701-5925
US

IV. Provider business mailing address

PO BOX 678284
DALLAS TX
75267-8284
US

V. Phone/Fax

Practice location:
  • Phone: 800-945-9877
  • Fax: 801-733-5618
Mailing address:
  • Phone: 907-452-2700
  • Fax: 801-773-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number217
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: