Basic Information
| Provider Information | |||||||||
| NPI: | 1306821970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAIMONDE | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 RALSTON AVE | ||||||||
| Address2: | DEPARTMENT OF SURGERY | ||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435121396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197836944 | ||||||||
| FaxNumber: | 4197834416 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 RALSTON AVE | ||||||||
| Address2: | DEPARTMENT OF SURGERY | ||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435121396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197836944 | ||||||||
| FaxNumber: | 4197834416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN-248250 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2207589 | 05 | OH | MEDICAID | 000000223183 | 01 | OH | ANTHEM | OTHER |