Healthcare Provider Details

I. General information

NPI: 1578055588
Provider Name (Legal Business Name): JEREMIAH S MOSSMAN APRN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21586 BELVEDERE LN
ESTERO FL
33928
US

IV. Provider business mailing address

21586 BELVEDERE LN
ESTERO FL
33928-7329
US

V. Phone/Fax

Practice location:
  • Phone: 478-973-0824
  • Fax:
Mailing address:
  • Phone: 478-973-0824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9383766
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: