Healthcare Provider Details

I. General information

NPI: 1669015087
Provider Name (Legal Business Name): JUSTIN PATRICK YELVERTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 POINT LOOKOUT RD
LEONARDTOWN MD
20650-2015
US

IV. Provider business mailing address

11663 ROYAL LYTHAM LN
WALDORF MD
20602-5192
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-8981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAC002977
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: