Healthcare Provider Details

I. General information

NPI: 1912366469
Provider Name (Legal Business Name): DENIS ETTA AWU CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 PARK STREET
MALONE NY
12953
US

IV. Provider business mailing address

133 PARK STREET
MALONE NY
12953
US

V. Phone/Fax

Practice location:
  • Phone: 678-665-1056
  • Fax:
Mailing address:
  • Phone: 678-665-1056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number110076
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: