Healthcare Provider Details

I. General information

NPI: 1811999642
Provider Name (Legal Business Name): JACK COLT BLAINE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6709 ACADEMY RD NE STE A
ALBUQUERQUE NM
87109-3363
US

IV. Provider business mailing address

36720 PALM CT
RANCHO MIRAGE CA
92270-2206
US

V. Phone/Fax

Practice location:
  • Phone: 505-312-4712
  • Fax:
Mailing address:
  • Phone: 619-994-2941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0061
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP108435
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA1771
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA00868
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: