Healthcare Provider Details

I. General information

NPI: 1295273126
Provider Name (Legal Business Name): JEREMY MORTENSEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2017
Last Update Date: 02/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

3240 BERMUDA ISLE CIR APT 930
NAPLES FL
34109-3214
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0895
  • Fax:
Mailing address:
  • Phone: 801-608-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54460
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: