Healthcare Provider Details

I. General information

NPI: 1285711143
Provider Name (Legal Business Name): PHILIP JENKINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 INDIAN WELLS RD
ALAMOGORDO NM
88310-4611
US

IV. Provider business mailing address

209 S MAIN ST
POPLAR BLUFF MO
63901-5831
US

V. Phone/Fax

Practice location:
  • Phone: 505-437-0890
  • Fax:
Mailing address:
  • Phone: 573-686-5550
  • Fax: 573-686-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR16286
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: