Healthcare Provider Details

I. General information

NPI: 1609360965
Provider Name (Legal Business Name): DAVID VELASCO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S MAIN ST
CROWN POINT IN
46307-8481
US

IV. Provider business mailing address

1302 FRANKLIN AVE
NORMAL IL
61761-3551
US

V. Phone/Fax

Practice location:
  • Phone: 219-757-6390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28227148A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209020777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: