Healthcare Provider Details

I. General information

NPI: 1689904492
Provider Name (Legal Business Name): MICHIAL JAMES LARGEN JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 S MAIN ST
DANVILLE VA
24541-2922
US

IV. Provider business mailing address

PO BOX 10824
BIRMINGHAM AL
35202-0824
US

V. Phone/Fax

Practice location:
  • Phone: 434-799-2375
  • Fax:
Mailing address:
  • Phone: 800-800-1617
  • Fax: 866-759-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0001153799
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: