Healthcare Provider Details

I. General information

NPI: 1437677820
Provider Name (Legal Business Name): JARED EARL DUMAS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N DR MARTIN LUTHER KING JR BLVD
CLOVIS NM
88101-9412
US

IV. Provider business mailing address

2113 JADYN LN
CLOVIS NM
88101-1617
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2141
  • Fax:
Mailing address:
  • Phone: 208-316-1676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01508
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: