Healthcare Provider Details

I. General information

NPI: 1881238178
Provider Name (Legal Business Name): ANGE BARLY TAPCHOM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 ARDLEY DR
ROSEVILLE CA
95747-9017
US

IV. Provider business mailing address

3217 ARDLEY DR
ROSEVILLE CA
95747-9017
US

V. Phone/Fax

Practice location:
  • Phone: 734-781-5534
  • Fax:
Mailing address:
  • Phone: 734-781-5534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN238664
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: