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General NPI Number Information
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NPI Number | 1053942284
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Entity Type | Individual
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Provider Name | ROY DEGRANGE JR.
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Gender | Male
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Dates
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Enumeration Date | 01/27/2020
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Last Update Date | 06/09/2020
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Provider Practice Location Address
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Address Line | 400 W 7TH ST
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City | FREDERICK
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State | MD
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Zip | 21701-4506
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Country | US
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Telephone | 250-566-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 6215 MARGARITA WAY
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City | FREDERICK
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State | MD
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Zip | 21703-2894
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Country | US
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Telephone | 301-471-8912
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | R204452
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | R204452
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License Number State | MD
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