Healthcare Provider Details

I. General information

NPI: 1245250489
Provider Name (Legal Business Name): ERIC ROGER NELSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 W 4TH AVE
TOPPENISH WA
98948-1616
US

IV. Provider business mailing address

732 SUMMITVIEW AVE #633
YAKIMA WA
98902-3032
US

V. Phone/Fax

Practice location:
  • Phone: 509-865-3105
  • Fax: 509-574-4481
Mailing address:
  • Phone: 509-573-3448
  • Fax: 509-574-4481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30007383
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: