Healthcare Provider Details

I. General information

NPI: 1942550728
Provider Name (Legal Business Name): BRYAN COLE CHALK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH STREET
WILMINGTON NC
28401
US

IV. Provider business mailing address

7612 CULLODEN COURT
WILMINGTON NC
28411
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-5831
  • Fax:
Mailing address:
  • Phone: 252-414-0453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number91147
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: