MEDICARE: MR. JEFFREY D. WEERTMAN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	640445	TX

General Provider Information

NPI Number	:	1487631685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY D. WEERTMAN CRNA

Provider Business Mailing Address
First Line	:	2309 FOREST PARK CIR
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-7643
Country	:	US
Telephone Number	:	817-473-1329
Fax Number	:

Provider Business Practice Location Address
First Line	:	6501 HARRIS PARKWAY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2122
Country	:	US
Telephone Number	:	817-346-3800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	01/22/2008

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