Healthcare Provider Details

I. General information

NPI: 1194223347
Provider Name (Legal Business Name): JUSTIN M SAUDER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S SHOOP AVE
WAUSEON OH
43567-1702
US

IV. Provider business mailing address

313 MADISON ST
WAUSEON OH
43567-1123
US

V. Phone/Fax

Practice location:
  • Phone: 419-335-2015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.019607
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: