Healthcare Provider Details

I. General information

NPI: 1053608109
Provider Name (Legal Business Name): JOHN ARNOLD SANDRU CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2417 ATRIUM DR STE 101
RALEIGH NC
27607-6673
US

IV. Provider business mailing address

PO BOX 946619
ATLANTA GA
30394-6619
US

V. Phone/Fax

Practice location:
  • Phone: 800-242-5080
  • Fax: 727-900-7981
Mailing address:
  • Phone: 800-242-5080
  • Fax: 727-900-7770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD-127601
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3220
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: