Healthcare Provider Details

I. General information

NPI: 1447671565
Provider Name (Legal Business Name): GEORGE ROBERT I. VICTORIANO III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MALL DR
HANFORD CA
93230-5786
US

IV. Provider business mailing address

1332 N LINDA VISTA CT
VISALIA CA
93291-3287
US

V. Phone/Fax

Practice location:
  • Phone: 956-867-1655
  • Fax:
Mailing address:
  • Phone: 956-867-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101380
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: