Healthcare Provider Details

I. General information

NPI: 1053942284
Provider Name (Legal Business Name): ROY DEGRANGE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 7TH ST
FREDERICK MD
21701-4506
US

IV. Provider business mailing address

6215 MARGARITA WAY
FREDERICK MD
21703-2894
US

V. Phone/Fax

Practice location:
  • Phone: 250-566-3300
  • Fax:
Mailing address:
  • Phone: 301-471-8912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR204452
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR204452
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: