Healthcare Provider Details

I. General information

NPI: 1962499954
Provider Name (Legal Business Name): DANIEL MASSENGALE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 FRONT ST RIVERSIDE ASSOC IN ANESTHESIA PC
BINGHAMTON NY
13905-4712
US

IV. Provider business mailing address

RIVERSIDE ASSOC IN ANESTHESIA 40 FRONT ST. STE C
BINGHAMTON NY
13905
US

V. Phone/Fax

Practice location:
  • Phone: 607-722-7264
  • Fax: 607-722-7869
Mailing address:
  • Phone: 607-722-7264
  • Fax: 607-722-7869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number533659
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number533659
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number054081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: