Healthcare Provider Details

I. General information

NPI: 1205378098
Provider Name (Legal Business Name): JACOB RAY BECK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WALLACE BLVD
AMARILLO TX
79106-1799
US

IV. Provider business mailing address

PO BOX 840853
DALLAS TX
75284-2502
US

V. Phone/Fax

Practice location:
  • Phone: 806-212-2000
  • Fax:
Mailing address:
  • Phone: 972-715-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN664861
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number912946
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number116076
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP133544
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: