Healthcare Provider Details

I. General information

NPI: 1134192420
Provider Name (Legal Business Name): JOEL PATRICK LAROSE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 OAK HILLS TRL
LEDYARD CT
06339-1234
US

IV. Provider business mailing address

2 OAK HILLS TRL
LEDYARD CT
06339-1234
US

V. Phone/Fax

Practice location:
  • Phone: 860-464-5514
  • Fax: 860-464-5514
Mailing address:
  • Phone: 860-464-5514
  • Fax: 860-464-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number002040
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: