Healthcare Provider Details

I. General information

NPI: 1639709173
Provider Name (Legal Business Name): KEITH LATASIEWICZ DNP-CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEITH LATASIEWICZ ARNP

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

V. Phone/Fax

Practice location:
  • Phone: 190-495-3200
  • Fax:
Mailing address:
  • Phone: 904-953-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11005942
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: