Healthcare Provider Details

I. General information

NPI: 1538189956
Provider Name (Legal Business Name): ROBERT MINEO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 HERRICK ROAD
SOUTHAMPTON NY
11968
US

IV. Provider business mailing address

PO BOX 7025
AMAGANSETT NY
11930
US

V. Phone/Fax

Practice location:
  • Phone: 631-726-8350
  • Fax: 631-726-8519
Mailing address:
  • Phone: 631-329-6925
  • Fax: 632-329-6951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number340862
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: