Healthcare Provider Details

I. General information

NPI: 1003911520
Provider Name (Legal Business Name): CHARLES DAVID LAINE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MILL AVE
TEMPE AZ
85281-6699
US

IV. Provider business mailing address

862 N PINEVIEW DR
CHANDLER AZ
85226-1919
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-5500
  • Fax:
Mailing address:
  • Phone: 480-940-3895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN083051
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: