Healthcare Provider Details

I. General information

NPI: 1720635873
Provider Name (Legal Business Name): CARL DELA CRUZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 03/08/2022
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 TELEGRAPH AVE
OAKLAND CA
94609-3239
US

IV. Provider business mailing address

2383 N MAIN ST UNIT 317
WALNUT CREEK CA
94596-3551
US

V. Phone/Fax

Practice location:
  • Phone: 510-869-6511
  • Fax:
Mailing address:
  • Phone: 925-325-6597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95052605
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: