Healthcare Provider Details

I. General information

NPI: 1003882077
Provider Name (Legal Business Name): BAN BATU CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18100 OAKWOOD BLVD STE 100
DEARBORN MI
48124-4085
US

IV. Provider business mailing address

3047 SUMERLYN CT
AUBURN HILLS MI
48326-1799
US

V. Phone/Fax

Practice location:
  • Phone: 313-253-2030
  • Fax:
Mailing address:
  • Phone: 586-718-3030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704212005
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: