Healthcare Provider Details

I. General information

NPI: 1396724191
Provider Name (Legal Business Name): DAVID THOMAS RUPERT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 MEMORIAL CT
JACKSONVILLE NC
28546-3209
US

IV. Provider business mailing address

200 HAMPSHIRE PL
JACKSONVILLE NC
28546-3209
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-9565
  • Fax:
Mailing address:
  • Phone: 910-353-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number124495
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: