Healthcare Provider Details

I. General information

NPI: 1770521437
Provider Name (Legal Business Name): JAMES LEE HEYREND CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 N DORIAN DR
ONTARIO OR
97914-1827
US

IV. Provider business mailing address

702 N DORIAN DR
ONTARIO OR
97914-1827
US

V. Phone/Fax

Practice location:
  • Phone: 208-740-4134
  • Fax: 541-889-6114
Mailing address:
  • Phone: 208-740-4134
  • Fax: 541-889-6114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number220083
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number51143
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: