Healthcare Provider Details

I. General information

NPI: 1386671253
Provider Name (Legal Business Name): GREG JUNG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MACK LANE MEDICAL ASSOCIATES CLINIC,LLP
PIERRE SD
57501
US

IV. Provider business mailing address

100 MACK LANE MEDICAL ASSOCIATES CLINIC,LLP
PIERRE SD
57501
US

V. Phone/Fax

Practice location:
  • Phone: 605-224-5901
  • Fax: 605-945-5296
Mailing address:
  • Phone: 605-224-5901
  • Fax: 605-945-5296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR014413
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: