Healthcare Provider Details

I. General information

NPI: 1720182710
Provider Name (Legal Business Name): CODY RANDY CHARLTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAPLE ST
FARMINGTON NM
87401-5630
US

IV. Provider business mailing address

PO BOX 3570
SALT LAKE CITY UT
84110-3570
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-2258
  • Fax: 505-609-2259
Mailing address:
  • Phone: 801-727-2056
  • Fax: 770-701-6675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01505
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5130028-4406
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP127707
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: