Healthcare Provider Details

I. General information

NPI: 1306821970
Provider Name (Legal Business Name): JON M RAIMONDE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 11/03/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 RALSTON AVE DEPARTMENT OF SURGERY
DEFIANCE OH
43512-1396
US

IV. Provider business mailing address

1200 RALSTON AVE DEPARTMENT OF SURGERY
DEFIANCE OH
43512-1396
US

V. Phone/Fax

Practice location:
  • Phone: 419-783-6944
  • Fax: 419-783-4416
Mailing address:
  • Phone: 419-783-6944
  • Fax: 419-783-4416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN-248250
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: