Healthcare Provider Details

I. General information

NPI: 1780854802
Provider Name (Legal Business Name): DAVID LYNN PROFFER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W TIPTON ST
SEYMOUR IN
47274-2363
US

IV. Provider business mailing address

411 W TIPTON ST
SEYMOUR IN
47274-2363
US

V. Phone/Fax

Practice location:
  • Phone: 812-522-0429
  • Fax:
Mailing address:
  • Phone: 812-522-0429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28175002A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: