Healthcare Provider Details

I. General information

NPI: 1275732141
Provider Name (Legal Business Name): STEPHEN JOHN DUMARESQ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MAIN STREET UNIT B
HYANNIS MA
02601-3127
US

IV. Provider business mailing address

69 STERLING RD
HYANNIS MA
02601-3656
US

V. Phone/Fax

Practice location:
  • Phone: 508-775-5011
  • Fax:
Mailing address:
  • Phone: 508-862-2554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number077642
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: