Healthcare Provider Details

I. General information

NPI: 1770999757
Provider Name (Legal Business Name): BENJAMIN RAY SWINEY CRNA, MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MDG/RAF LAKENHEATH UNIT 5115
APO AE
09461-5115
US

IV. Provider business mailing address

48MDG/RAF LAKENHEATH UNIT 5115
APO AE
09461-5115
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-7028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number18383
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: