Healthcare Provider Details

I. General information

NPI: 1104984566
Provider Name (Legal Business Name): DAVID LEE PERKINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

PO BOX 134
SEASIDE OR
97138-0134
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-3589
  • Fax:
Mailing address:
  • Phone: 707-628-9721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3251
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60415098
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number200960022CRNA
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: