=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366032914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL ROBERT BERNARD CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2021
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 MATTHEW ST
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-1635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-568-5427
-----------------------------------------------------
Fax | 740-376-5073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 372
-----------------------------------------------------
City | MATTOON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61938-0372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 209.029228
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | APRN.CRNA.0021136
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------