Healthcare Provider Details

I. General information

NPI: 1508301110
Provider Name (Legal Business Name): MATTHEW MCINTIRE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3404 W SYLVANIA AVE
TOLEDO OH
43623-4467
US

IV. Provider business mailing address

6225 STATE HWY 161 STE 200
IRVING TX
75038-2241
US

V. Phone/Fax

Practice location:
  • Phone: 419-407-2663
  • Fax:
Mailing address:
  • Phone: 214-687-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN.377934
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: