Healthcare Provider Details

I. General information

NPI: 1750938635
Provider Name (Legal Business Name): CHRISTIAN RANDOLPH KOERNER CNS-AG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2019
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7940 SUMTER RIDGE LN APT 5110
RALEIGH NC
27617-6734
US

IV. Provider business mailing address

7940 SUMTER RIDGE LN APT 5110
RALEIGH NC
27617-6734
US

V. Phone/Fax

Practice location:
  • Phone: 910-805-0306
  • Fax:
Mailing address:
  • Phone: 919-400-5011
  • Fax: 919-400-5809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number547
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number303322
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: