Healthcare Provider Details

I. General information

NPI: 1790730299
Provider Name (Legal Business Name): GORDON DIETZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 E MAIN ST BERTRAND CHAFFEE HOSPITAL
SPRINGVILLE NY
14141-1443
US

IV. Provider business mailing address

224 E MAIN ST BERTRAND CHAFFEE HOSPITAL
SPRINGVILLE NY
14141-1443
US

V. Phone/Fax

Practice location:
  • Phone: 716-592-2871
  • Fax: 716-794-0025
Mailing address:
  • Phone: 716-592-2871
  • Fax: 716-794-0025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR103713
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: