Healthcare Provider Details

I. General information

NPI: 1548713258
Provider Name (Legal Business Name): JIM LEE PEREZ CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DR
SISSETON SD
57262-7046
US

IV. Provider business mailing address

152 SHADOW OAKS DR
ELGIN TX
78621-8910
US

V. Phone/Fax

Practice location:
  • Phone: 605-698-7606
  • Fax:
Mailing address:
  • Phone: 512-293-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP137073
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: