Basic Information
| Provider Information | |||||||||
| NPI: | 1679927594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADWAN | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5112 MOSER LN | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517189 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1404 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435122440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197828444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2016 | ||||||||
| LastUpdateDate: | 04/17/2016 | ||||||||
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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 | RN.391335- | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.