Healthcare Provider Details

I. General information

NPI: 1427227875
Provider Name (Legal Business Name): JOSE LUIS ESTRADA JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2008
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

IV. Provider business mailing address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7856
  • Fax:
Mailing address:
  • Phone: 904-542-7632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9331689
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001175596
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024167864
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: