Healthcare Provider Details

I. General information

NPI: 1164761367
Provider Name (Legal Business Name): ADRIAN JOHN GENOTTI III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4431 1/2 HERSCHEL ST
JACKSONVILLE FL
32210-3301
US

IV. Provider business mailing address

4431 1/2 HERSCHEL ST
JACKSONVILLE FL
32210-3301
US

V. Phone/Fax

Practice location:
  • Phone: 904-866-6711
  • Fax:
Mailing address:
  • Phone: 904-866-6711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9281093
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: