Healthcare Provider Details

I. General information

NPI: 1952290231
Provider Name (Legal Business Name): MITCHELL PATRICK GALE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25-1 HAMJEONG-RI, PAENGSEONG-EUP
APO AP
96271
US

IV. Provider business mailing address

205 PALISADE RDG
EVANS GA
30809-0608
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-1125
  • Fax:
Mailing address:
  • Phone: 404-518-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN220603
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: