Healthcare Provider Details

I. General information

NPI: 1790714152
Provider Name (Legal Business Name): FRANK JOSEPH DAUGHERTY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 1ST ST
MINEOLA NY
11501-3901
US

IV. Provider business mailing address

30 LITTLE NECK RD
CENTERPORT NY
11721-1668
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-2216
  • Fax:
Mailing address:
  • Phone: 631-239-1323
  • Fax: 631-239-1323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number407130
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: