Provider Demographics
NPI:1639610330
Name:SAMPLE, STEVEN D JR (CRNA)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:SAMPLE
Suffix:JR
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:PO BOX 4918
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32802-4918
Mailing Address - Country:US
Mailing Address - Phone:407-581-9180
Mailing Address - Fax:865-560-7066
Practice Address - Street 1:225 E ROBINSON ST
Practice Address - Street 2:SUITE 130
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-4322
Practice Address - Country:US
Practice Address - Phone:407-581-9180
Practice Address - Fax:865-560-7066
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA220350207LC0200X
FLARNP9387609367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered