Provider Demographics
NPI:1952587693
Name:PACKARD, PAUL ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ALAN
Last Name:PACKARD
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 1:810 FAIRGROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-9617
Mailing Address - Country:US
Mailing Address - Phone:828-326-3809
Mailing Address - Fax:828-326-3371
Practice Address - Street 1:810 FAIRGROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9617
Practice Address - Country:US
Practice Address - Phone:828-326-3809
Practice Address - Fax:828-326-3371
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR60668367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053111Medicaid
NCP00744395OtherRAILROAD MEDICARE
NC8053111Medicaid