Healthcare Provider Details

I. General information

NPI: 1710457866
Provider Name (Legal Business Name): KENNETH FRANK DAGLES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PARK ST
GLENS FALLS NY
12801-4447
US

IV. Provider business mailing address

194 HALL HILL RD
LAKE LUZERNE NY
12846-3509
US

V. Phone/Fax

Practice location:
  • Phone: 518-926-1000
  • Fax:
Mailing address:
  • Phone: 518-744-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number646847
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: