Provider Demographics
NPI:1164405684
Name:PRECIADO, CARL A (CRNA)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:A
Last Name:PRECIADO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE PT STE 300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4569
Practice Address - Country:US
Practice Address - Phone:864-522-3700
Practice Address - Fax:864-522-3705
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR83960367500000X
SC1354367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400097OtherMEDICAID - GROUP
SCAN1056Medicaid
SC1152OtherMEDICARE - GROUP
SCGP2991Medicaid
SC6877Medicare PIN
SCQ32744Medicare ID - Type Unspecified
SCAN1056Medicaid
SCQ32744Medicare PIN