Healthcare Provider Details

I. General information

NPI: 1780781443
Provider Name (Legal Business Name): ERIC BRIAN EWALD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21298 OLEAN BLVD
PORT CHARLOTTE FL
33952-6705
US

IV. Provider business mailing address

3415 KNOX TER
PORT CHARLOTTE FL
33948-2215
US

V. Phone/Fax

Practice location:
  • Phone: 941-629-1181
  • Fax:
Mailing address:
  • Phone: 941-421-4162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number69110
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9490042
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: