Healthcare Provider Details

I. General information

NPI: 1144236274
Provider Name (Legal Business Name): ROGER W ZANDER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22211 MORLEY AVE
DEARBORN MI
48124-2110
US

IV. Provider business mailing address

22211 MORLEY AVE
DEARBORN MI
48124-2110
US

V. Phone/Fax

Practice location:
  • Phone: 313-492-5056
  • Fax: 313-565-8156
Mailing address:
  • Phone: 313-492-5056
  • Fax: 313-565-8156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704118315
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: