Healthcare Provider Details

I. General information

NPI: 1083892780
Provider Name (Legal Business Name): DANNY COLEMAN SANDEFUR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEALY AVE
LANGLEY AFB VA
23665-2040
US

IV. Provider business mailing address

6 QUAIL CV
POQUOSON VA
23662-1742
US

V. Phone/Fax

Practice location:
  • Phone: 702-236-2862
  • Fax:
Mailing address:
  • Phone: 702-236-2862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024171324
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: