Healthcare Provider Details

I. General information

NPI: 1134493596
Provider Name (Legal Business Name): THOMAS A OPILKA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 HISTORIC HWY 441 N
DEMOREST GA
30535
US

IV. Provider business mailing address

PO BOX 369
TURNERVILLE GA
30580-0369
US

V. Phone/Fax

Practice location:
  • Phone: 706-839-6205
  • Fax: 706-754-9668
Mailing address:
  • Phone: 706-839-6205
  • Fax: 706-754-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN194877
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: