Healthcare Provider Details

I. General information

NPI: 1629062500
Provider Name (Legal Business Name): JOHN GREGORY SANFORD CRNA-MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CAPEHART RD
OFFUTT A F B NE
68113-1043
US

IV. Provider business mailing address

1105 MAGNOLIA CIR
PAPILLION NE
68046-6218
US

V. Phone/Fax

Practice location:
  • Phone: 402-294-2135
  • Fax:
Mailing address:
  • Phone: 402-614-8402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100742
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: