Healthcare Provider Details

I. General information

NPI: 1861822116
Provider Name (Legal Business Name): MICHAEL LEE LOUDNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2013
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E ADAMS ST RM 4143
SYRACUSE NY
13210-1834
US

IV. Provider business mailing address

5784 WIDEWATERS PKWY FLOOR 2
SYRACUSE NY
13214-1890
US

V. Phone/Fax

Practice location:
  • Phone: 315-469-4891
  • Fax: 315-464-4905
Mailing address:
  • Phone: 315-469-1130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number535456
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number535456
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: