Healthcare Provider Details

I. General information

NPI: 1073176921
Provider Name (Legal Business Name): JESSE ALAN HYDE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 TOWER RD STE 201
DAKOTA DUNES SD
57049-5098
US

IV. Provider business mailing address

101 TOWER RD STE 201
DAKOTA DUNES SD
57049-5098
US

V. Phone/Fax

Practice location:
  • Phone: 605-217-7246
  • Fax:
Mailing address:
  • Phone: 605-217-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCR001020
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: