Healthcare Provider Details

I. General information

NPI: 1154617744
Provider Name (Legal Business Name): NICHOLAS SORRELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 SUMMER VIEW CT
CONROE TX
77303-2269
US

IV. Provider business mailing address

7 SUMMER VIEW CT
CONROE TX
77303-2269
US

V. Phone/Fax

Practice location:
  • Phone: 402-304-4487
  • Fax:
Mailing address:
  • Phone: 402-304-4487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number64351
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: