Healthcare Provider Details

I. General information

NPI: 1376909853
Provider Name (Legal Business Name): JASON WALTHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MOBILE INFIRMARY CIR
MOBILE AL
36607-3513
US

IV. Provider business mailing address

PO BOX 11407 DEPT 1499
BIRMINGHAM AL
35246-1499
US

V. Phone/Fax

Practice location:
  • Phone: 251-435-2400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-129814
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: