Healthcare Provider Details

I. General information

NPI: 1649787326
Provider Name (Legal Business Name): SPENCER JONATHAN GARRISON CRNA, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASTEUR DR
STANFORD CA
94305-2200
US

IV. Provider business mailing address

28 LANSING LN
PALM COAST FL
32137-9627
US

V. Phone/Fax

Practice location:
  • Phone: 650-723-4000
  • Fax:
Mailing address:
  • Phone: 386-559-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number117527
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001417
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: