Healthcare Provider Details

I. General information

NPI: 1760825145
Provider Name (Legal Business Name): JEREMY ALAN BULLOCK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 03/19/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 S 4TH ST
LEBANON PA
17042-6111
US

IV. Provider business mailing address

601 MEMORY LN
YORK PA
17402-2231
US

V. Phone/Fax

Practice location:
  • Phone: 717-270-7500
  • Fax: 717-228-1642
Mailing address:
  • Phone: 717-851-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN528480L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: