Healthcare Provider Details

I. General information

NPI: 1932694346
Provider Name (Legal Business Name): ELIJAH SAMUEL VINCENT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W LEOTA ST
NORTH PLATTE NE
69101-6525
US

IV. Provider business mailing address

17118 SILLS DR
PRAIRIEVILLE LA
70769-3494
US

V. Phone/Fax

Practice location:
  • Phone: 308-568-8000
  • Fax:
Mailing address:
  • Phone: 225-939-1038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101500
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: