Healthcare Provider Details

I. General information

NPI: 1063439834
Provider Name (Legal Business Name): JUANCHO C. DEPAOLO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S CRISMON RD
MESA AZ
85209-3767
US

IV. Provider business mailing address

21215 E VALLEJO ST
QUEEN CREEK AZ
85142-5332
US

V. Phone/Fax

Practice location:
  • Phone: 800-402-0881
  • Fax:
Mailing address:
  • Phone: 407-864-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0791
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: