Healthcare Provider Details

I. General information

NPI: 1396805958
Provider Name (Legal Business Name): PETER L PROCKO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86208 SAND HICKORY TRL
YULEE FL
32097-4295
US

IV. Provider business mailing address

86208 SAND HICKORY TRL
YULEE FL
32097-4295
US

V. Phone/Fax

Practice location:
  • Phone: 904-556-1404
  • Fax:
Mailing address:
  • Phone: 904-556-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN090565
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberARNP1961972
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN090565
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3390
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA113009
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: