Healthcare Provider Details

I. General information

NPI: 1982780961
Provider Name (Legal Business Name): MITCHELL MIZE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOSPITAL DR
GALAX VA
24333-2227
US

IV. Provider business mailing address

1260 POPLAR KNOB ROAD
GALAX VA
24333
US

V. Phone/Fax

Practice location:
  • Phone: 276-236-8181
  • Fax:
Mailing address:
  • Phone: 276-236-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024165925
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: