Healthcare Provider Details

I. General information

NPI: 1740829514
Provider Name (Legal Business Name): JAH AUGUSTUS MCLERNAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2019
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 CANTON ST # 204
WESTWOOD MA
02090-2321
US

IV. Provider business mailing address

310 CONCORD AVE
CAMBRIDGE MA
02138-1208
US

V. Phone/Fax

Practice location:
  • Phone: 339-204-9516
  • Fax: 781-459-4698
Mailing address:
  • Phone: 508-523-9205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN274043
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN274043
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: