Healthcare Provider Details

I. General information

NPI: 1205206067
Provider Name (Legal Business Name): AKEEM JAMAL SCOTT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 POPLAR ST APT. 1
KINGSTON PA
18704-3709
US

IV. Provider business mailing address

78 POPLAR ST APT. 1
KINGSTON PA
18704-3709
US

V. Phone/Fax

Practice location:
  • Phone: 215-416-1624
  • Fax:
Mailing address:
  • Phone: 215-416-1624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN604983
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: