MEDICARE: DANETTE LYNNE CROASTON CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	61484	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104006386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANETTE LYNNE CROASTON CRNA

Provider Business Mailing Address
First Line	:	111 LONE PINE DR
Second Line	:
City	:	MASONTOWN
State	:	WV
Zip	:	26542-8605
Country	:	US
Telephone Number	:	304-376-6557
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 LONE PINE DR
Second Line	:
City	:	MASONTOWN
State	:	WV
Zip	:	26542-8605
Country	:	US
Telephone Number	:	304-376-6557
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2007
Last Update Date	:	07/18/2016

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