Basic Information
| Provider Information | |||||||||
| NPI: | 1790881621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK DUPRE | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUPRE | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 714813 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372930247 | ||||||||
| FaxNumber: | 9372930960 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 MEDICAL DRIVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458044099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192247586 | ||||||||
| FaxNumber: | 4192249769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 037246 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN149531 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0583328 | 01 | OH | BCMH | OTHER | 2135684 | 05 | OH | MEDICAID | 000000515999 | 01 | OH | ANTHEM | OTHER | 037246 | 01 | OH | CRNA LICENSE | OTHER | 746241 | 01 | OH | BUCKEYE MEDICAID | OTHER | 000000226089 | 01 | OH | UNISON | OTHER | 414347 | 01 | OH | WELLCARE MEDICAID | OTHER | 7441733 | 01 | AETNA | OTHER |