Healthcare Provider Details

I. General information

NPI: 1164594669
Provider Name (Legal Business Name): THOMAS J DREDLA III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4021 AVENUE B
SCOTTSBLUFF NE
69361-4602
US

IV. Provider business mailing address

4021 AVENUE B
SCOTTSBLUFF NE
69361-4602
US

V. Phone/Fax

Practice location:
  • Phone: 308-641-1311
  • Fax: 308-630-1656
Mailing address:
  • Phone: 308-641-1311
  • Fax: 308-630-1656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100028
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: