Healthcare Provider Details

I. General information

NPI: 1073772612
Provider Name (Legal Business Name): GREENSBORO ANESTHESIA SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 E HUNDRED RD STE 104
CHESTER VA
23836-3310
US

IV. Provider business mailing address

400 10TH ST E
WACONIA MN
55387-4552
US

V. Phone/Fax

Practice location:
  • Phone: 888-209-0305
  • Fax: 952-442-3620
Mailing address:
  • Phone: 888-209-0305
  • Fax: 952-442-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JOHN MICHAEL NULTY
Title or Position: PRESIDENT
Credential: CRNA
Phone: 336-324-3116