Provider Demographics
NPI:1679546790
Name:MCCOMB, BRIAN D (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:MCCOMB
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 1:301 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5167
Mailing Address - Country:US
Mailing Address - Phone:386-231-6000
Mailing Address - Fax:
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-882-6350
Practice Address - Fax:386-882-6720
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9225026367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306917600Medicaid
FL306917600Medicaid