Healthcare Provider Details

I. General information

NPI: 1396078812
Provider Name (Legal Business Name): JASON E. MINA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 SCRANTON CARBONDALE HWY
SCRANTON PA
18508-1115
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-3034
US

V. Phone/Fax

Practice location:
  • Phone: 570-558-6372
  • Fax:
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN559274
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: