Healthcare Provider Details

I. General information

NPI: 1831965342
Provider Name (Legal Business Name): COLLIN BARRETT MERCURI STAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 HOUSTON CT
HAW RIVER NC
27258-8853
US

IV. Provider business mailing address

808 HOUSTON CT
HAW RIVER NC
27258-8853
US

V. Phone/Fax

Practice location:
  • Phone: 315-720-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number160205
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: