Basic Information
| Provider Information | |||||||||
| NPI: | 1659674638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETWILER | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 GOLF ACRES DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282085906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045126428 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD. | ||||||||
| Address2: | CAROLINAS MEDICAL CENTER | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2010 | ||||||||
| LastUpdateDate: | 12/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 195055 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 195055 | 01 | NC | NORTH CAROLINA BOARD OF NURSING | OTHER | NAN014 | 05 | SC | MEDICAID | 8054164 | 05 | NC | MEDICAID |