Healthcare Provider Details

I. General information

NPI: 1053616649
Provider Name (Legal Business Name): JASON ALAN GOFF CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BASE NAVAL DE ROTA APARTADO DE CORREOS 33
ROTA CADIZ
11530
ES

IV. Provider business mailing address

PSC 819 BOX 18
FPO AE
09645-0001
US

V. Phone/Fax

Practice location:
  • Phone: 317-523-4733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number085229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: