Provider Demographics
NPI:1396805958
Name:PROCKO, PETER L (CRNA)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:L
Last Name:PROCKO
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 1:86208 SAND HICKORY TRL
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-4295
Mailing Address - Country:US
Mailing Address - Phone:904-556-1404
Mailing Address - Fax:
Practice Address - Street 1:86208 SAND HICKORY TRL
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-4295
Practice Address - Country:US
Practice Address - Phone:904-556-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN090565163WC0200X, 367500000X
FLARNP1961972163WC0200X
SC3390367500000X
MERNA113009367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00378017OtherRRB
GA000559237LMedicaid
GAP00378017Medicare PIN
GA43BBCSRMedicare PIN