Provider Demographics
NPI:1902872062
Name:MCCOUCHA, MATTHEW LAMAR (CRNA NURSE ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LAMAR
Last Name:MCCOUCHA
Suffix:
Gender:M
Credentials:CRNA NURSE ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1040 GULF BREEZE PARKWAY
Mailing Address - Street 2:ANDREWS INSTITUTE FOR ORTHOPAEDICS & SPORTS MEDICINE
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561
Mailing Address - Country:US
Mailing Address - Phone:850-916-8700
Mailing Address - Fax:850-916-8509
Practice Address - Street 1:NAVAL HOSPITAL GREAT LAKES, 3001 A 6TH STREET
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024140275367500000X
FLARNP9296655367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered