Basic Information
| Provider Information | |||||||||
| NPI: | 1225018088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ULMER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 NOVUS DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376048237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232830776 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1009 NOVUS DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376048237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232830776 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APN 9624 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN 83185 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AANA 31399 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3608926 | 05 | TN | MEDICAID | 74012550 | 05 | KY | MEDICAID | 010270111 | 05 | VA | MEDICAID | 3058690 | 01 | BLUE CROSS OF TENNESSEE | OTHER |