Healthcare Provider Details

I. General information

NPI: 1689774267
Provider Name (Legal Business Name): BARRY ALAN VANCE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 MARTIN LOOP
FORT BENNING GA
31905-5647
US

IV. Provider business mailing address

4560 CARNOUSTIE LN
COLUMBUS GA
31909-8039
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-1442
  • Fax:
Mailing address:
  • Phone: 706-573-5067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN70036
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: