Healthcare Provider Details

I. General information

NPI: 1851330666
Provider Name (Legal Business Name): CECIL TIMOTHY JACKSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HIGHWAY 91 SOUTH C/O BARRETT HOSPITAL & HEALTHCARE
DILLON MT
59725-3597
US

IV. Provider business mailing address

203 S DAISY ST
SALMON ID
83467-4709
US

V. Phone/Fax

Practice location:
  • Phone: 406-683-3000
  • Fax: 406-683-3011
Mailing address:
  • Phone: 208-756-2429
  • Fax: 208-756-2429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number29774
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: