Healthcare Provider Details

I. General information

NPI: 1396166815
Provider Name (Legal Business Name): JAY AMMON ELLEFSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 CHESTER AVE
BAKERSFIELD CA
93301-2014
US

IV. Provider business mailing address

2635 G ST
BAKERSFIELD CA
93301-2813
US

V. Phone/Fax

Practice location:
  • Phone: 661-633-1500
  • Fax: 661-633-2700
Mailing address:
  • Phone: 661-633-1500
  • Fax: 661-633-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: