Provider Demographics
NPI:1427344977
Name:BOGART, ROSARIO WALTER (CRNA)
Entity type:Individual
Prefix:
First Name:ROSARIO
Middle Name:WALTER
Last Name:BOGART
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 1:146 MEDICAL PARK RD
Mailing Address - Street 2:STE 108
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8529
Mailing Address - Country:US
Mailing Address - Phone:704-662-0877
Mailing Address - Fax:704-662-0875
Practice Address - Street 1:131 MEDICAL PARK RD
Practice Address - Street 2:308
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8522
Practice Address - Country:US
Practice Address - Phone:704-662-0876
Practice Address - Fax:704-662-0875
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA087329367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered