Healthcare Provider Details

I. General information

NPI: 1457451726
Provider Name (Legal Business Name): TIMOTEO JUAN CHACON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 CITRUS TOWER BLVD SUITE 4
CLERMONT FL
34711-1957
US

IV. Provider business mailing address

100 SUN AVE NE STE 650
ALBUQUERQUE NM
87109-4670
US

V. Phone/Fax

Practice location:
  • Phone: 352-243-9114
  • Fax: 352-243-7822
Mailing address:
  • Phone: 505-260-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9201656
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: