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General NPI Number Information
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NPI Number | 1396805958
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Entity Type | Individual
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Provider Name | PETER L PROCKO CRNA
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Gender | Male
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 12/29/2016
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Provider Practice Location Address
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Address Line | 86208 SAND HICKORY TRL
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City | YULEE
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State | FL
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Zip | 32097-4295
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Country | US
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Telephone | 904-556-1404
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Fax |
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Provider Business Mailing Address
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Address Line | 86208 SAND HICKORY TRL
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City | YULEE
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State | FL
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Zip | 32097-4295
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Country | US
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Telephone | 904-556-1404
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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 | 163WC0200X
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Taxonomy Name | Critical Care Medicine Registered Nurse
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License Number | RN090565
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 163WC0200X
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Taxonomy Name | Critical Care Medicine Registered Nurse
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License Number | ARNP1961972
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RN090565
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 3390
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License Number State | SC
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Taxonomy #5
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RNA113009
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License Number State | ME
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