Healthcare Provider Details

I. General information

NPI: 1124426218
Provider Name (Legal Business Name): KEVIN CHARLES STAPLES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10628 PARK RD
CHARLOTTE NC
28210-8407
US

IV. Provider business mailing address

4400 GOLF ACRES DR STE A
CHARLOTTE NC
28208-5906
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-1000
  • Fax:
Mailing address:
  • Phone: 704-512-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number220418
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: