Healthcare Provider Details

I. General information

NPI: 1013470335
Provider Name (Legal Business Name): DAVID KIM HOANG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

IV. Provider business mailing address

1616 33RD ST SE
RIO RANCHO NM
87124-1702
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-7000
  • Fax:
Mailing address:
  • Phone: 316-765-4698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13-127191-022
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number557731
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number61518
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: