Healthcare Provider Details

I. General information

NPI: 1093282279
Provider Name (Legal Business Name): JASON FERNANDES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 BURDETT AVE
TROY NY
12180-2475
US

IV. Provider business mailing address

86 PROVIDENCE LN
PALM COAST FL
32164-4758
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-8600
  • Fax:
Mailing address:
  • Phone: 386-503-8825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11000815
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number839415
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: