Provider Demographics
NPI:1477697621
Name:HARTZ, KENNETH IVAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:IVAN
Last Name:HARTZ
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 1:308 ROLLINGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-3249
Mailing Address - Country:US
Mailing Address - Phone:252-533-0580
Mailing Address - Fax:
Practice Address - Street 1:250 SMITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4914
Practice Address - Country:US
Practice Address - Phone:252-535-8185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC121072367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered