Healthcare Provider Details

I. General information

NPI: 1336803436
Provider Name (Legal Business Name): MR. JARED R BOAZ MCCULLOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 7TH ST N
NAPLES FL
34102-5754
US

IV. Provider business mailing address

7933 UMBERTO CT
NAPLES FL
34114-2688
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11017759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: