Basic Information
| Provider Information | |||||||||
| NPI: | 1851393623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERAAD | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26699 MOHAWK DR | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435515403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196907652 | ||||||||
| FaxNumber: | 4196977726 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 BAY PARK DR | ||||||||
| Address2: | DEPARTMENT OF SURGERY | ||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436164920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196907652 | ||||||||
| FaxNumber: | 4196977726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 08/19/2009 | ||||||||
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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 | 367500000X | 4238A | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN 279724 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P00619434 | 01 | RRMC | OTHER | 000000556304 | 01 | ANTHEM | OTHER | 341881145-003 | 01 | OH | MMO | OTHER | 04097A | 01 | OH | PARAMOUNT | OTHER | 5182096 | 05 | MI | MEDICAID | 74007279 | 05 | KY | MEDICAID |