Healthcare Provider Details

I. General information

NPI: 1275852378
Provider Name (Legal Business Name): JEROMY EUGENE TEAGUE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 05/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 HOSPITAL DR
MORRILTON AR
72110-4510
US

IV. Provider business mailing address

1630 JASMINE LN
CONWAY AR
72034-8446
US

V. Phone/Fax

Practice location:
  • Phone: 501-977-2300
  • Fax:
Mailing address:
  • Phone: 501-908-5249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCTP-000137
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: