Healthcare Provider Details

I. General information

NPI: 1922040062
Provider Name (Legal Business Name): ROBERT KEITH LANDIS C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8292 S RIDGE DR
MACUNGIE PA
18062-9138
US

IV. Provider business mailing address

8292 S RIDGE DR
MACUNGIE PA
18062-9138
US

V. Phone/Fax

Practice location:
  • Phone: 610-966-3163
  • Fax:
Mailing address:
  • Phone: 610-966-3163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-254765L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041740
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: