Healthcare Provider Details

I. General information

NPI: 1497736243
Provider Name (Legal Business Name): RANDY DANIEL MCDONALD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 LLEWELLYN AVE KIMBROUGH AMBULATORY CARE CENTER
FT MEADE MD
20755-5800
US

IV. Provider business mailing address

2480 LLEWELLYN AVE KIMBROUGH AMBULATORY CARE CENTER
FT MEADE MD
20755-5800
US

V. Phone/Fax

Practice location:
  • Phone: 301-677-8011
  • Fax:
Mailing address:
  • Phone: 301-677-8011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number380-708-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: