Healthcare Provider Details

I. General information

NPI: 1548705148
Provider Name (Legal Business Name): BLAKE JACKMAN PULVER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1236 E ELIZABETH ST STE 1
FORT COLLINS CO
80524
US

IV. Provider business mailing address

1236 E ELIZABETH ST STE 1
FORT COLLINS CO
80524-4000
US

V. Phone/Fax

Practice location:
  • Phone: 970-224-2985
  • Fax:
Mailing address:
  • Phone: 970-224-2985
  • Fax: 970-472-9381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC-APN.0001041-C-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: