Healthcare Provider Details

I. General information

NPI: 1942715412
Provider Name (Legal Business Name): SAMUEL O BURT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1139 E HIGH ST STE 203
CHARLOTTESVILLE VA
22902-4849
US

IV. Provider business mailing address

7746 S 164TH DR
GOODYEAR AZ
85338-5836
US

V. Phone/Fax

Practice location:
  • Phone: 434-817-8484
  • Fax: 434-817-8490
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number240773
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number076895-21
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024190708
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: