Healthcare Provider Details

I. General information

NPI: 1619582467
Provider Name (Legal Business Name): NATHANAEL RUMBA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 FRANCISCAN WAY
MICHIGAN CITY IN
46360-0021
US

IV. Provider business mailing address

1401 LA PORTE AVENUE
VALPARAISO IN
46383
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-8511
  • Fax:
Mailing address:
  • Phone: 765-418-6554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28191016A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: