Healthcare Provider Details

I. General information

NPI: 1962554741
Provider Name (Legal Business Name): WALTER L PENDERGRAST CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST NHRMC ANESTHESIA DEPT.
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

2131 S 17TH ST NHRMC ANESTHESIA DEPT.
WILMINGTON NC
28401-7407
US

V. Phone/Fax

Practice location:
  • Phone: 910-772-9202
  • Fax: 910-772-9452
Mailing address:
  • Phone: 910-772-9202
  • Fax: 910-772-9452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number080616
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: