Healthcare Provider Details

I. General information

NPI: 1417599366
Provider Name (Legal Business Name): NICHOLAS JACOB BETTINGER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MCGREGOR ST
MANCHESTER NH
03102-3730
US

IV. Provider business mailing address

21 DARBY LN
BEDFORD NH
03110-4517
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-3545
  • Fax:
Mailing address:
  • Phone: 423-903-0826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number181927
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number128755
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: