Provider Demographics
NPI:1710694336
Name:MORTIMER, CHAD (CRNA)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:MORTIMER
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 1:3670 STRAWBERRY HL
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9278
Mailing Address - Country:US
Mailing Address - Phone:330-219-9180
Mailing Address - Fax:
Practice Address - Street 1:4135 BOARDMAN CANFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9803
Practice Address - Country:US
Practice Address - Phone:330-286-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.416494163WC0200X
OHAPRN.CRNA.0021356367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine