Provider Demographics
NPI:1972688174
Name:SEPULVEDA, NOE (CRNA)
Entity Type:Individual
Prefix:
First Name:NOE
Middle Name:
Last Name:SEPULVEDA
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:PO BOX 650782
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0782
Mailing Address - Country:US
Mailing Address - Phone:302-733-0806
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:501 W FRONT ST
Practice Address - Street 2:
Practice Address - City:ELMER
Practice Address - State:NJ
Practice Address - Zip Code:08318-2101
Practice Address - Country:US
Practice Address - Phone:856-363-1000
Practice Address - Fax:877-329-2370
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR10556800163W00000X
PARN354200L163W00000X
NJ26NJ00207900367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ110412Medicare PIN