Healthcare Provider Details

I. General information

NPI: 1336683747
Provider Name (Legal Business Name): DAVID J KRASUCKI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DAVID GRANT MEDICAL CENTER 101 BODIN CIR
TRAVIS AFB CA
94535
US

IV. Provider business mailing address

60 MDG/SGCJ 101 BODIN CIR
TRAVIS AFB CA
94535
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5370
  • Fax:
Mailing address:
  • Phone: 707-423-5370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberL6-0A00769
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: