Healthcare Provider Details

I. General information

NPI: 1144550799
Provider Name (Legal Business Name): KINGSLEY L MALCOLM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2010
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WEST ST
CARTHAGE NY
13619-9703
US

IV. Provider business mailing address

2824 RADER RIDGE CT
ANTIOCH TN
37013-5748
US

V. Phone/Fax

Practice location:
  • Phone: 315-493-1000
  • Fax:
Mailing address:
  • Phone: 615-424-3918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number511702-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: