Healthcare Provider Details

I. General information

NPI: 1053323170
Provider Name (Legal Business Name): DALLAS D. REGAN CRNA, DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

100 OVERLOOK TER #62
NEW YORK NY
10040-3852
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-7641
  • Fax:
Mailing address:
  • Phone: 917-698-3688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201403680CRNA
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201909433CRNA-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: