Healthcare Provider Details

I. General information

NPI: 1184160293
Provider Name (Legal Business Name): JUSTIN SCOTT ROSE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 15TH ST NW
NORTON VA
24273-1616
US

IV. Provider business mailing address

933 OLD WILDERNESS RD
SALTVILLE VA
24370-4229
US

V. Phone/Fax

Practice location:
  • Phone: 276-439-1425
  • Fax:
Mailing address:
  • Phone: 276-782-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024174579
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001231492
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: