Healthcare Provider Details

I. General information

NPI: 1174611883
Provider Name (Legal Business Name): JAMES GOODE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 VAN DUSEN RD
LAUREL MD
20707-9463
US

IV. Provider business mailing address

11517 LADY ALISON CT
WALDORF MD
20601-4627
US

V. Phone/Fax

Practice location:
  • Phone: 443-332-4088
  • Fax: 410-793-0809
Mailing address:
  • Phone: 240-607-9061
  • Fax: 240-607-9061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR1800054
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: