Healthcare Provider Details

I. General information

NPI: 1396775615
Provider Name (Legal Business Name): MIKEAL SIDNEY WOODS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 BELLE CHASSE HWY
GRETNA LA
70056
US

IV. Provider business mailing address

1514 JEFFERSON HIGHWAY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-842-3755
  • Fax:
Mailing address:
  • Phone: 504-842-9119
  • Fax: 504-842-6997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN028523
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP02355
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: