Healthcare Provider Details

I. General information

NPI: 1073594461
Provider Name (Legal Business Name): JERRY EDWARD GLATTFELT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BODIN CIR 60 TH MSGS/SGCSA
TRAVIS AFB CA
94535-1804
US

IV. Provider business mailing address

1131 PARK LN
SUISUN CITY CA
94585-2878
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5370
  • Fax:
Mailing address:
  • Phone: 707-428-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041-232449
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-003657 APN LICEN
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: