Healthcare Provider Details

I. General information

NPI: 1295038628
Provider Name (Legal Business Name): JAMEY ROBERT WILMOTH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 MARTIN AVE
EPHRATA PA
17522-1724
US

IV. Provider business mailing address

28 EGYPT RD
NORRISTOWN PA
19403-3002
US

V. Phone/Fax

Practice location:
  • Phone: 717-738-6618
  • Fax: 717-738-6646
Mailing address:
  • Phone: 610-220-2913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN502629L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: