Healthcare Provider Details

I. General information

NPI: 1639400773
Provider Name (Legal Business Name): GREGORY DAVID POWELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 BRAEBURN GLEN DR
MINDEN LA
71055-5798
US

IV. Provider business mailing address

318 BRAEBURN GLEN DR
MINDEN LA
71055-5798
US

V. Phone/Fax

Practice location:
  • Phone: 318-245-1725
  • Fax:
Mailing address:
  • Phone: 318-245-1725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number083219
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: