Basic Information
| Provider Information | |||||||||
| NPI: | 1669587911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGRA | ||||||||
| FirstName: | ARLENE | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36151 GRAFTON EASTERN RD | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440449637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168708471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 860 EAST BROAD STREET | ||||||||
| Address2: | SUITE I | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403238458 | ||||||||
| FaxNumber: | 4403237900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 203557 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2625949 | 05 | OH | MEDICAID |