Healthcare Provider Details

I. General information

NPI: 1225322001
Provider Name (Legal Business Name): JOSEPH LEE SANDERSON JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 TAWANA CT
KNIGHTDALE NC
27545-7647
US

IV. Provider business mailing address

1001 TAWANA CT
KNIGHTDALE NC
27545-7647
US

V. Phone/Fax

Practice location:
  • Phone: 919-218-6824
  • Fax:
Mailing address:
  • Phone: 919-218-6824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number216787
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number088362
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9334361
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: