Healthcare Provider Details

I. General information

NPI: 1760619100
Provider Name (Legal Business Name): NICHOLAS SEAN BANCROFT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MEDICAL GROUP RAF LAKENHEATH UNIT 5115
APO AE
09461-5115
US

IV. Provider business mailing address

1974 SERVICEBERRY RD
DUMFRIES VA
22026-2890
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8124
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4186
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number662359
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: