Healthcare Provider Details

I. General information

NPI: 1134194525
Provider Name (Legal Business Name): DAVID GOUDREAU CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST DAVOL 129
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

690 CANTON ST STE 325
WESTWOOD MA
02090-2324
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4933
  • Fax: 401-444-5090
Mailing address:
  • Phone: 401-490-0916
  • Fax: 401-490-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number136964
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: