Basic Information
| Provider Information | |||||||||
| NPI: | 1467425306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUCKEY | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 ONE STRAIGHT DR | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490368845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192292622 | ||||||||
| FaxNumber: | 4192292646 | ||||||||
| Practice Location | |||||||||
| Address1: | 2740 NAVARRE AVE | ||||||||
| Address2: | |||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436163216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196934444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 06/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | COA.02581-NA | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0758309 | 05 | OH | MEDICAID | 4704165719 | 01 | MI | MI LICENSE | OTHER |