Healthcare Provider Details

I. General information

NPI: 1770727158
Provider Name (Legal Business Name): MICHAEL ANGELO TANTAY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 NW 20TH PLACE UNIT NO 511
PORTLAND OR
97209-1042
US

IV. Provider business mailing address

125 NW 20TH PL UNIT NO511
PORTLAND OR
97209-1042
US

V. Phone/Fax

Practice location:
  • Phone: 714-334-4787
  • Fax:
Mailing address:
  • Phone: 714-334-4787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3851
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201060008
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: