Healthcare Provider Details

I. General information

NPI: 1225010259
Provider Name (Legal Business Name): ROBERT MCCOY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12345 W BEND DR
SAINT LOUIS MO
63128-2182
US

IV. Provider business mailing address

PO BOX 22407
SAINT LOUIS MO
63126-0407
US

V. Phone/Fax

Practice location:
  • Phone: 147-222-5303
  • Fax:
Mailing address:
  • Phone: 363-867-2226
  • Fax: 363-867-8106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number026929
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: