Provider Demographics
NPI:1720252430
Name:BROCK, DANIEL PERRY (CRNA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:PERRY
Last Name:BROCK
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 1:406 ASHLAND DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-9165
Mailing Address - Country:US
Mailing Address - Phone:252-341-8278
Mailing Address - Fax:
Practice Address - Street 1:2601 LAKE DR STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6689
Practice Address - Country:US
Practice Address - Phone:919-341-3623
Practice Address - Fax:919-782-1669
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC181529163W00000X
NC079666367500000X
NC2099367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053243Medicaid
NC1720252430OtherTRICARE
NCP00631832OtherRAILROAD MEDICARE
NC8053243Medicaid