Healthcare Provider Details

I. General information

NPI: 1386156115
Provider Name (Legal Business Name): SETH GULLETT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 N COUNTY ROAD 25A
TROY OH
45373-1337
US

IV. Provider business mailing address

1153 SKYLARK DR
TROY OH
45373-1845
US

V. Phone/Fax

Practice location:
  • Phone: 937-440-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number112964
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: