Healthcare Provider Details

I. General information

NPI: 1568230829
Provider Name (Legal Business Name): DANIEL LOCK BOATRIGHT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N PATTERSON ST
VALDOSTA GA
31602-1735
US

IV. Provider business mailing address

247 SW JEWEL LAKE DR
LAKE CITY FL
32024-0662
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-6852
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11030208
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: