Healthcare Provider Details

I. General information

NPI: 1437398229
Provider Name (Legal Business Name): JEREMY CARLISLE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEREMY CARLISLE CRNA

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/24/2024
Certification Date: 02/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 14TH AVE SW
SIDNEY MT
59270-3519
US

IV. Provider business mailing address

216 14TH AVE SW
SIDNEY MT
59270-3519
US

V. Phone/Fax

Practice location:
  • Phone: 406-488-2100
  • Fax:
Mailing address:
  • Phone: 406-488-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number37444
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: