Healthcare Provider Details

I. General information

NPI: 1528010881
Provider Name (Legal Business Name): PATRICK L JENKINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 HOWARDS CREEK MILL RD
VALE NC
28168-6711
US

IV. Provider business mailing address

1161 HOWARDS CREEK MILL RD
VALE NC
28168-6711
US

V. Phone/Fax

Practice location:
  • Phone: 704-276-3629
  • Fax:
Mailing address:
  • Phone: 704-276-3629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number169237
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: