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1851393623

NPI Code Detail

MEDICARE: GARY A DERAAD CRNA

MEDICARE: GARY A DERAAD 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	3004238	KY
2	367500000X	Certified Registered Nurse Anesthetist	RN 279724	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00619434	OTHER		RRMC
2	000000556304	OTHER		ANTHEM
3	341881145-003	OTHER	OH	MMO
4	04097A	OTHER	OH	PARAMOUNT
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851393623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY A DERAAD CRNA

Provider Business Mailing Address
First Line	:	26699 MOHAWK DR
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-5403
Country	:	US
Telephone Number	:	419-690-7652
Fax Number	:	419-697-7726

Provider Business Practice Location Address
First Line	:	800 ROSE ST
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40536-7001
Country	:	US
Telephone Number	:	859-323-5956
Fax Number	:	859-323-1080

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	09/22/2025

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Directions to “ GARY A DERAAD CRNA” Practice Location

Language	Start Address	Practice Location

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