Healthcare Provider Details

I. General information

NPI: 1447858725
Provider Name (Legal Business Name): ANTHONY MONTELLA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

610 W GERMANTOWN PIKE STE 150
PLYMOUTH MEETING PA
19462-1062
US

V. Phone/Fax

Practice location:
  • Phone: 610-526-3000
  • Fax: 517-787-2922
Mailing address:
  • Phone: 610-526-3000
  • Fax: 517-787-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN626765
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: