Healthcare Provider Details

I. General information

NPI: 1548646151
Provider Name (Legal Business Name): JESSE GESTEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

IV. Provider business mailing address

4200 WATERTOWN PL
COLUMBIA MO
65203-6812
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-6262
  • Fax:
Mailing address:
  • Phone: 928-699-7306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number106431
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1398
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: