Healthcare Provider Details

I. General information

NPI: 1104996438
Provider Name (Legal Business Name): RONALD L BROCKETT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 CENTER AVE
ROMNEY WV
26757-1352
US

IV. Provider business mailing address

549 CENTER AVE
ROMNEY WV
26757-1352
US

V. Phone/Fax

Practice location:
  • Phone: 304-822-4651
  • Fax: 304-822-7809
Mailing address:
  • Phone: 304-822-4651
  • Fax: 304-822-7809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28779
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: