Healthcare Provider Details

I. General information

NPI: 1932674835
Provider Name (Legal Business Name): NICHOLAS WILLARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2018
Last Update Date: 10/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAPITAL WAY
PENNINGTON NJ
08534-2520
US

IV. Provider business mailing address

180C TAYLORSVILLE RD
WASHINGTON CROSSING PA
18977-1608
US

V. Phone/Fax

Practice location:
  • Phone: 800-637-2374
  • Fax:
Mailing address:
  • Phone: 215-450-2343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ00846500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: