Provider Demographics
NPI:1144399965
Name:MUSHETT, ALLEN P (CRNA)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:P
Last Name:MUSHETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 E GRACE ST
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-3211
Mailing Address - Country:US
Mailing Address - Phone:219-866-5141
Mailing Address - Fax:219-866-3234
Practice Address - Street 1:1104 E GRACE ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-3211
Practice Address - Country:US
Practice Address - Phone:219-866-5141
Practice Address - Fax:219-866-3234
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28126868A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000297276OtherBLUE CROSS
IN200412680AMedicaid
INCC9310AMedicare ID - Type Unspecified
INP00103475Medicare ID - Type UnspecifiedMEDICARE RR INDIANA
IN000000297276OtherBLUE CROSS