Healthcare Provider Details

I. General information

NPI: 1174550925
Provider Name (Legal Business Name): JORGE MANUEL BALLESTEROS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3714 S SUMMERLIN AVE
ORLANDO FL
32806-6902
US

IV. Provider business mailing address

3714 S SUMMERLIN AVE
ORLANDO FL
32806-6902
US

V. Phone/Fax

Practice location:
  • Phone: 812-240-0977
  • Fax:
Mailing address:
  • Phone: 812-240-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR56975
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: