Provider Demographics
NPI:1780781443
Name:EWALD, ERIC BRIAN (CRNA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:BRIAN
Last Name:EWALD
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 1:3415 KNOX TER
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-2215
Mailing Address - Country:US
Mailing Address - Phone:941-421-4162
Mailing Address - Fax:
Practice Address - Street 1:21298 OLEAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6705
Practice Address - Country:US
Practice Address - Phone:941-629-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV69110367500000X
FLAPRN9490042367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810008119OtherMEDICAID
WV8238851OtherMEDICARE PTAN