Healthcare Provider Details

I. General information

NPI: 1467731695
Provider Name (Legal Business Name): PAUL TALMAGE BROCK II CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 ERWIN ROAD
DURHAM NC
27705-3941
US

IV. Provider business mailing address

PO BOX 751274
CHARLOTTE NC
28275-1274
US

V. Phone/Fax

Practice location:
  • Phone: 919-620-4917
  • Fax: 919-620-4921
Mailing address:
  • Phone: 919-620-4917
  • Fax: 919-620-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209106
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: