Healthcare Provider Details

I. General information

NPI: 1972083400
Provider Name (Legal Business Name): TYSON SCOTT HADERLIE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 7TH ST N
NAPLES FL
34102-5754
US

IV. Provider business mailing address

5913 SUNSET RIVER AVE
LAS VEGAS NV
89131-2133
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-5000
  • Fax:
Mailing address:
  • Phone: 435-730-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number834775
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number125894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: