Healthcare Provider Details

I. General information

NPI: 1831698299
Provider Name (Legal Business Name): JUSTIN STEVENSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36053 EAGLE LN
BEAUMONT CA
92223-8005
US

IV. Provider business mailing address

36053 EAGLE LN
BEAUMONT CA
92223-8005
US

V. Phone/Fax

Practice location:
  • Phone: 801-598-6473
  • Fax:
Mailing address:
  • Phone: 801-598-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95068824
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP137237
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: