Healthcare Provider Details

I. General information

NPI: 1417069865
Provider Name (Legal Business Name): MARK RICHARD DIRIENZO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 KIMEL PARK DR SUITE 300
WINSTON SALEM NC
27103-6984
US

IV. Provider business mailing address

145 KIMEL PARK DR SUITE 300
WINSTON SALEM NC
27103-6984
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3212
  • Fax: 336-768-9019
Mailing address:
  • Phone: 336-768-3212
  • Fax: 336-768-9019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number093106
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: