MEDICARE: MR. DAVID OWEN DICK CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist		VA

General Provider Information

NPI Number	:	1740234020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID OWEN DICK CRNA

Provider Business Mailing Address
First Line	:	1504 CORNWELL LN
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2517
Country	:	US
Telephone Number	:	757-496-2419
Fax Number	:	757-496-2419

Provider Business Practice Location Address
First Line	:	1504 CORNWELL LN
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2517
Country	:	US
Telephone Number	:	757-496-2419
Fax Number	:	757-496-2419

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	07/08/2007

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