Healthcare Provider Details

I. General information

NPI: 1255309357
Provider Name (Legal Business Name): JASON D RICHMOND CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-5368
  • Fax: 505-913-5375
Mailing address:
  • Phone: 505-913-5368
  • Fax: 505-913-5375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR1557345
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA 01071
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: