Healthcare Provider Details

I. General information

NPI: 1598061053
Provider Name (Legal Business Name): CHRISTOPHER DOUGLAS KYLE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 JOSEPH SIEWICK DR
FAIRFAX VA
22033-1709
US

IV. Provider business mailing address

68 S SERVICE RD
MELVILLE NY
11747-2358
US

V. Phone/Fax

Practice location:
  • Phone: 703-664-7048
  • Fax: 703-644-7402
Mailing address:
  • Phone: 516-945-3000
  • Fax: 516-945-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024169251
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR191518
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA4420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: