Healthcare Provider Details

I. General information

NPI: 1538491303
Provider Name (Legal Business Name): JUSTIN BRANDON FARRIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 WINTERSAGE CIR
TALENT OR
97540-9515
US

IV. Provider business mailing address

262 WINTERSAGE CIR
TALENT OR
97540-9515
US

V. Phone/Fax

Practice location:
  • Phone: 719-362-7848
  • Fax:
Mailing address:
  • Phone: 719-362-7848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201501661CRNA
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: