Healthcare Provider Details

I. General information

NPI: 1255366365
Provider Name (Legal Business Name): DATHAN LOUIS ENOCH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 STATE ROUTE 33
NEPTUNE NJ
07753-4859
US

IV. Provider business mailing address

1 FEDERAL ST STE 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 732-776-4945
  • Fax: 732-776-4550
Mailing address:
  • Phone: 848-288-6935
  • Fax: 732-790-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN518186L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ14853900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: