Provider Demographics
NPI:1639154537
Name:IDERA, MICHELE (CRNA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:IDERA
Suffix:
Gender:F
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:1551 E TANGERINE RD
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6213
Practice Address - Country:US
Practice Address - Phone:520-901-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA2932367500000X
AZCRNA1498367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN3489390Medicaid
CACB210411Medicare PIN
CARN3489390Medicaid
CAP00024096Medicare PIN