Healthcare Provider Details

I. General information

NPI: 1912329780
Provider Name (Legal Business Name): NELSON MAX ROSE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-5631
US

IV. Provider business mailing address

PO BOX 100254
GAINESVILLE FL
32610-0254
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8610
  • Fax: 352-273-8612
Mailing address:
  • Phone: 352-273-8610
  • Fax: 352-273-8612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberAPRN11018225
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11018225
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: