Basic Information
| Provider Information | |||||||||
| NPI: | 1073581351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DISTASIO | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | DOMBKOWSKI | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1901 ULMERTON RD | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337622300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275737777 | ||||||||
| FaxNumber: | 7275737710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 7TH AVE N | ||||||||
| Address2: | ANESTHESIA DEPT | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278251100 | ||||||||
| FaxNumber: | 7275737710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP2139842 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 009278100 | 05 | FL | MEDICAID | G1251 | 01 | FL | BCBS OF FLORIDA | OTHER |