Healthcare Provider Details

I. General information

NPI: 1447346499
Provider Name (Legal Business Name): KEVIN JAMES MALTAIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

568 RUIN CREEK RD SUITE 105
HENDERSON NC
27536-2880
US

IV. Provider business mailing address

400 E 10TH ST
WACONIA MN
55387-4552
US

V. Phone/Fax

Practice location:
  • Phone: 252-436-1380
  • Fax: 252-436-1851
Mailing address:
  • Phone: 952-442-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024167055
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number181612
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: