Healthcare Provider Details

I. General information

NPI: 1477193274
Provider Name (Legal Business Name): RICHARD BRUCE MENSIK JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

IV. Provider business mailing address

105 LOCUST DR
NEWARK DE
19711-2713
US

V. Phone/Fax

Practice location:
  • Phone: 302-709-4709
  • Fax:
Mailing address:
  • Phone: 865-898-1888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberL6-0A00817
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: