MEDICARE: MR. NICHOLAS SEAN BANCROFT CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	4186	CA
2	163W00000X	Registered Nurse	662359	CA

General Provider Information

NPI Number	:	1760619100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS SEAN BANCROFT CRNA

Provider Business Mailing Address
First Line	:	1974 SERVICEBERRY RD
Second Line	:
City	:	DUMFRIES
State	:	VA
Zip	:	22026-2890
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	48TH MEDICAL GROUP
Second Line	:	RAF LAKENHEATH UNIT 5115
City	:	APO
State	:	AE
Zip	:	09461-5115
Country	:	US
Telephone Number	:	314-226-8124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2009
Last Update Date	:	06/11/2026

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