Healthcare Provider Details

I. General information

NPI: 1164883468
Provider Name (Legal Business Name): JAMES DWAIN HOLDEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22888 COUNTY ROAD 283
PUXICO MO
63960-7338
US

IV. Provider business mailing address

22888 COUNTY ROAD 283
PUXICO MO
63960-7338
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-6655
  • Fax:
Mailing address:
  • Phone: 573-778-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2016008297
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: