Healthcare Provider Details

I. General information

NPI: 1841326782
Provider Name (Legal Business Name): LAWRENCE I INGBER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 COUNTRY CLUB RD STE 220B
EUGENE OR
97401-6090
US

IV. Provider business mailing address

3855 WALSH ST
JACKSONVILLE FL
32205-9223
US

V. Phone/Fax

Practice location:
  • Phone: 541-342-5012
  • Fax:
Mailing address:
  • Phone: 904-686-5017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN3023222
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3023222
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number200960010CRNA
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: