Healthcare Provider Details

I. General information

NPI: 1659752046
Provider Name (Legal Business Name): TERRY J POPE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 TANGERINE AVE
WINTER PARK FL
32792-7236
US

IV. Provider business mailing address

5050 TANGERINE AVE
WINTER PARK FL
32792-7236
US

V. Phone/Fax

Practice location:
  • Phone: 219-381-4256
  • Fax:
Mailing address:
  • Phone: 219-381-4256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 9346510
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: