Healthcare Provider Details

I. General information

NPI: 1538154828
Provider Name (Legal Business Name): STANLEY J KUPCHINSKY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 W RAVINE RD SUITE 5 B
KINGSPORT TN
37660-3847
US

IV. Provider business mailing address

PO BOX 1308
KINGSPORT TN
37662-1308
US

V. Phone/Fax

Practice location:
  • Phone: 423-224-3460
  • Fax: 423-224-3465
Mailing address:
  • Phone: 423-224-3460
  • Fax: 423-224-3465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9502
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: