Healthcare Provider Details

I. General information

NPI: 1184138679
Provider Name (Legal Business Name): BENJAMIN HENRIE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 08/14/2024
Certification Date: 08/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

167 MAIN ST
TUBA CITY AZ
86045
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-3366
  • Fax:
Mailing address:
  • Phone: 866-976-5941
  • Fax: 928-213-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number247924
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: