Healthcare Provider Details

I. General information

NPI: 1033220959
Provider Name (Legal Business Name): SETH CANNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E PARK AVE
STATE COLLEGE PA
16803-6701
US

IV. Provider business mailing address

1530 MARTIN ST
STATE COLLEGE PA
16803-3058
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-7000
  • Fax:
Mailing address:
  • Phone: 814-235-3898
  • Fax: 814-235-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN512605L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: