Healthcare Provider Details

I. General information

NPI: 1770928244
Provider Name (Legal Business Name): JESS FIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 POPLAR ST
BLACKFOOT ID
83221-1758
US

IV. Provider business mailing address

287 W 330 N
BLACKFOOT ID
83221-5170
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-3729
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60332807
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1529
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-881A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: