Healthcare Provider Details

I. General information

NPI: 1285641829
Provider Name (Legal Business Name): DALLAS SWIRE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

PO BOX 354
NARROWS VA
24124-0354
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001-058459
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024-058459
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: