Healthcare Provider Details

I. General information

NPI: 1366971533
Provider Name (Legal Business Name): JACK J MILES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 RESERVOIR RD NW
WASHINGTON DC
20007-2113
US

IV. Provider business mailing address

1441 U ST NW APT 708
WASHINGTON DC
20009-3530
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN1026396
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2276965
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: