Healthcare Provider Details

I. General information

NPI: 1225173966
Provider Name (Legal Business Name): ROMUALDO B REQUIJO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 ROSS CLARK CIR
DOTHAN AL
36301-3022
US

IV. Provider business mailing address

PO BOX 1928
DOTHAN AL
36302-1928
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-8087
  • Fax: 334-793-8191
Mailing address:
  • Phone: 334-793-8087
  • Fax: 334-793-8191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-093762
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: