Healthcare Provider Details

I. General information

NPI: 1366773921
Provider Name (Legal Business Name): PETER C KOMA C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3622 BELMONT AVE SUITE 1
YOUNGSTOWN OH
44505-1450
US

IV. Provider business mailing address

3622 BELMONT AVE SUITE 1
YOUNGSTOWN OH
44505-1450
US

V. Phone/Fax

Practice location:
  • Phone: 330-759-9350
  • Fax: 330-759-9387
Mailing address:
  • Phone: 330-759-9350
  • Fax: 330-759-9387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA 11297 NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: