Provider Demographics
NPI:1629052493
Name:ROUSE, CRYSTAL COLEMAN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:COLEMAN
Last Name:ROUSE
Suffix:
Gender:F
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:MEDICAL CENTER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-713-2745
Mailing Address - Fax:
Practice Address - Street 1:WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER
Practice Address - Street 2:MEDICAL CENTER BOULEVARD--NURSE ANESTHESIA DEPT.
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-713-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC153149367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051811Medicaid
NC8051811Medicaid