Healthcare Provider Details

I. General information

NPI: 1780098442
Provider Name (Legal Business Name): DANIEL FORREST SLACK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 07/14/2022
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 CAROLINE ST
PORT ANGELES WA
98362-3909
US

IV. Provider business mailing address

660 S COOLIDGE ST
MOSES LAKE WA
98837-1872
US

V. Phone/Fax

Practice location:
  • Phone: 360-417-7711
  • Fax:
Mailing address:
  • Phone: 509-793-9715
  • Fax: 509-764-3244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6134-33
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201606815CRNA-P
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number64001
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number712720
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60651342
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: