Healthcare Provider Details

I. General information

NPI: 1063513612
Provider Name (Legal Business Name): JEREMY MICHAEL DAVES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NW R D MIZE RD ANESTHESIA SERVICES OF BLUE SPRINGS/ST. MARY'S MEDICAL
BLUE SPRINGS MO
64014-2513
US

IV. Provider business mailing address

1209 NW NORTH RIDGE DRIVE SUITE B
BLUE SPRINGS MO
64015-6320
US

V. Phone/Fax

Practice location:
  • Phone: 816-988-8415
  • Fax: 816-335-4003
Mailing address:
  • Phone: 816-988-8415
  • Fax: 816-335-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2004031152
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: