Provider Demographics
NPI:1225018088
Name:ULMER, MICHAEL PHILIP (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILIP
Last Name:ULMER
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 1:1009 NOVUS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8237
Mailing Address - Country:US
Mailing Address - Phone:423-283-0776
Mailing Address - Fax:
Practice Address - Street 1:1009 NOVUS DR STE 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8237
Practice Address - Country:US
Practice Address - Phone:423-283-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN 9624367500000X
TNRN 83185367500000X
TNAANA 31399367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3608926Medicaid
KY74012550Medicaid
VA010270111Medicaid
3058690OtherBLUE CROSS OF TENNESSEE
TN3608927Medicare PIN
KY74012550Medicaid
VA009805W82Medicare PIN