Healthcare Provider Details

I. General information

NPI: 1255410593
Provider Name (Legal Business Name): JERRY EVAN COY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HOSPITAL DR
TARBORO NC
27886-2011
US

IV. Provider business mailing address

130 DEVONSHIRE LN
WILMINGTON NC
28409-8111
US

V. Phone/Fax

Practice location:
  • Phone: 252-641-7170
  • Fax: 252-641-7373
Mailing address:
  • Phone: 910-392-6902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number106170
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number106170
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: