Healthcare Provider Details

I. General information

NPI: 1972888774
Provider Name (Legal Business Name): JASON ANTHONY REDDINGIUS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16643 ROCKY CREEK DR
RIVERSIDE CA
92503-6545
US

IV. Provider business mailing address

16643 ROCKY CREEK DR
RIVERSIDE CA
92503-6545
US

V. Phone/Fax

Practice location:
  • Phone: 951-231-8105
  • Fax:
Mailing address:
  • Phone: 951-231-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4114
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: