Healthcare Provider Details

I. General information

NPI: 1902227283
Provider Name (Legal Business Name): CARL MILLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 8TH AVE NE
HAZEN ND
58545-4637
US

IV. Provider business mailing address

510 8TH AVE NE
HAZEN ND
58545-4637
US

V. Phone/Fax

Practice location:
  • Phone: 701-748-2225
  • Fax: 701-748-5757
Mailing address:
  • Phone: 701-748-2225
  • Fax: 701-748-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR32433
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: