Healthcare Provider Details

I. General information

NPI: 1700957578
Provider Name (Legal Business Name): GERARD GILBERT DESJARDINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E 17TH STREET
ROSWELL NM
88201
US

IV. Provider business mailing address

PO BOX 664
ROSWELL NM
88202
US

V. Phone/Fax

Practice location:
  • Phone: 575-627-7000
  • Fax: 575-627-7007
Mailing address:
  • Phone: 575-622-4784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR13732
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: