Healthcare Provider Details

I. General information

NPI: 1114973930
Provider Name (Legal Business Name): AUGUSTINE DEVITA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 ROUTE 70 E
CHERRY HILL NJ
08034-2409
US

IV. Provider business mailing address

804 SCOTT NIXON MEMORIAL DR
AUGUSTA GA
30907-2464
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-3867
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number10192700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: