MEDICARE: DAVID P CARELOCK 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	637274	TX
2	367500000X	Certified Registered Nurse Anesthetist	NA3375	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00C073M	OTHER	TX	BLUE CROSS BLUE SHIELD
3	109873101	OTHER	TX	FIRSTCARE

General Provider Information

NPI Number	:	1790773596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID P CARELOCK CRNA

Provider Business Mailing Address
First Line	:	PO BOX 7096
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95267-0096
Country	:	US
Telephone Number	:	209-956-7725
Fax Number	:	209-956-7733

Provider Business Practice Location Address
First Line	:	10 WOODLAND RD
Second Line	:
City	:	SAINT HELENA
State	:	CA
Zip	:	94574-9554
Country	:	US
Telephone Number	:	707-963-3611
Fax Number	:	254-200-4090

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

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	05/02/2013

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Directions to “ DAVID P CARELOCK CRNA” Practice Location

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