Provider Demographics
NPI:1760488381
Name:STEFONETTI, MICHAEL A (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:STEFONETTI
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 1:517 ASH ST
Mailing Address - Street 2:STE 1
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2903
Mailing Address - Country:US
Mailing Address - Phone:570-969-6100
Mailing Address - Fax:570-983-0267
Practice Address - Street 1:517 ASH ST
Practice Address - Street 2:STE 1
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-2903
Practice Address - Country:US
Practice Address - Phone:570-969-6100
Practice Address - Fax:570-983-0267
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN250024L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA763842MNJMedicare ID - Type Unspecified
PA763842F4NMedicare PIN