Healthcare Provider Details

I. General information

NPI: 1154626901
Provider Name (Legal Business Name): DAMIEN JOSEPH ROSTORFER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST UFJAX - DEPT. OF ANESTHESIOLOGY
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 44008 UFJP - PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-4195
  • Fax: 904-244-4908
Mailing address:
  • Phone: 904-244-3199
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9180005
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: