Provider Demographics
NPI:1104813021
Name:MCCUTCHEON, DEANA L (CRNA)
Entity type:Individual
Prefix:
First Name:DEANA
Middle Name:L
Last Name:MCCUTCHEON
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 1:3211 DUDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-1813
Mailing Address - Country:US
Mailing Address - Phone:304-422-3904
Mailing Address - Fax:304-422-3924
Practice Address - Street 1:1701 SOUTH BLVD E STE 300
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6120
Practice Address - Country:US
Practice Address - Phone:517-273-4695
Practice Address - Fax:304-422-3924
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704317883367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2366621Medicaid
MI1104813021OtherNPI
WV2603210000Medicaid