Provider Demographics
NPI:1962498808
Name:ZAZZERA, MARY BETH (CRNA)
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:ZAZZERA
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 1:210 LOOMIS RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:PA
Mailing Address - Zip Code:18801-9387
Mailing Address - Country:US
Mailing Address - Phone:570-313-5584
Mailing Address - Fax:
Practice Address - Street 1:210 LOOMIS RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:PA
Practice Address - Zip Code:18801-9387
Practice Address - Country:US
Practice Address - Phone:570-313-5584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY514096163W00000X
PARN333763L163W00000X
PA48112367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACC0926Medicare PIN
S58743Medicare UPIN