Provider Demographics
NPI:1366773921
Name:KOMA, PETER C (CRNA)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:C
Last Name:KOMA
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 1:3622 BELMONT AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1450
Mailing Address - Country:US
Mailing Address - Phone:330-759-9350
Mailing Address - Fax:330-759-9387
Practice Address - Street 1:3622 BELMONT AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1450
Practice Address - Country:US
Practice Address - Phone:330-759-9350
Practice Address - Fax:330-759-9387
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 11297 NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH301183 COA1OtherRN
OH3022455Medicaid
OH11297-NAOtherCOA
OH8246541Medicare PIN