Healthcare Provider Details

I. General information

NPI: 1790230886
Provider Name (Legal Business Name): JONATHAN GARDNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 FRESNO & R ST
FRESNO CA
93721-1324
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-6000
  • Fax: 559-498-8182
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA95000629
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: