Basic Information
| Provider Information | |||||||||
| NPI: | 1225024888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUETTERTIES | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PANCZNER | ||||||||
| OtherFirstName: | BONNIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 650782 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027330806 | ||||||||
| FaxNumber: | 3027330854 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 E CHESTER PIKE | ||||||||
| Address2: | |||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105956000 | ||||||||
| FaxNumber: | 8773292370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN208761L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 031377 | 01 | AANA NUMBER | OTHER | P00678824 | 01 | PA | RAILROAD MEDICARE | OTHER | 102336093 | 05 | PA | MEDICAID |