Basic Information
| Provider Information | |||||||||
| NPI: | 1508154592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAZZELLA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 ROANE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253022334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043440096 | ||||||||
| FaxNumber: | 3043424725 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 LAIDLEY ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043476500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2011 | ||||||||
| LastUpdateDate: | 12/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 48555 | WV | N | Nursing Service Providers | Registered Nurse | 367500000X | 085360 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3810021321 | 05 | WV | MEDICAID | Q37026A | 01 | WV | MEDICARE PTAN | OTHER | P00981780 | 01 | WV | MEDICARE RAILROAD | OTHER |