Healthcare Provider Details

I. General information

NPI: 1659463909
Provider Name (Legal Business Name): RICHARD WILLIAM COOKE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 E ELDER STREET
FALLBROOK CA
92028
US

IV. Provider business mailing address

PO BOX 522 IA
FALLBROOK CA
92088
US

V. Phone/Fax

Practice location:
  • Phone: 760-728-1191
  • Fax:
Mailing address:
  • Phone: 760-491-0072
  • Fax: 760-451-9072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number58039
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number403376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: