Provider Demographics
NPI:1659674638
Name:DETWILER, CHRISTINE MARGARET (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARGARET
Last Name:DETWILER
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 1:4400 GOLF ACRES DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5906
Mailing Address - Country:US
Mailing Address - Phone:704-512-6428
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD.
Practice Address - Street 2:CAROLINAS MEDICAL CENTER
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203
Practice Address - Country:US
Practice Address - Phone:704-355-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC195055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC195055OtherNORTH CAROLINA BOARD OF NURSING
SCNAN014Medicaid
NC8054164Medicaid
SCNAN014Medicaid