Healthcare Provider Details

I. General information

NPI: 1457737850
Provider Name (Legal Business Name): NICHOLAS I. CUPPS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 E 3RD ST
CHATTANOOGA TN
37403-2147
US

IV. Provider business mailing address

PO BOX 2930
INDIANAPOLIS IN
46206-2930
US

V. Phone/Fax

Practice location:
  • Phone: 423-602-8400
  • Fax: 423-602-8401
Mailing address:
  • Phone: 423-892-5602
  • Fax: 423-892-5838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN191912
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: