Provider Demographics
NPI:1144559956
Name:DEETER, KEVEN L (CRNA)
Entity type:Individual
Prefix:MR
First Name:KEVEN
Middle Name:L
Last Name:DEETER
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 1:2114 STATE ROUTE 113 E
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:OH
Mailing Address - Zip Code:44846-9483
Mailing Address - Country:US
Mailing Address - Phone:419-499-4500
Mailing Address - Fax:419-499-1219
Practice Address - Street 1:2114 STATE ROUTE 113 E
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:OH
Practice Address - Zip Code:44846-9483
Practice Address - Country:US
Practice Address - Phone:419-499-4500
Practice Address - Fax:419-499-1219
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered