Healthcare Provider Details

I. General information

NPI: 1710461694
Provider Name (Legal Business Name): KEVIN MATTHEW TIRADO ROMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 EDWIN RD
DURHAM NC
27710-0001
US

IV. Provider business mailing address

504 E PETTIGREW ST APT 249
DURHAM NC
27701-4467
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-8111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number124099
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: