Provider Demographics
NPI:1063514438
Name:MARCUKAITIS, ANTHONY WENDELL (CRNA)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WENDELL
Last Name:MARCUKAITIS
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 1:8350 JOY RD
Mailing Address - Street 2:
Mailing Address - City:KALEVA
Mailing Address - State:MI
Mailing Address - Zip Code:49645-9686
Mailing Address - Country:US
Mailing Address - Phone:517-974-3236
Mailing Address - Fax:
Practice Address - Street 1:1585 THIRD ST
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704215056367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered