Healthcare Provider Details

I. General information

NPI: 1104838234
Provider Name (Legal Business Name): JACK STOUT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E RIDGE RD SUITE 204
MCALLEN TX
78503-1251
US

IV. Provider business mailing address

PO BOX 1672
SAN ANTONIO TX
78296-1672
US

V. Phone/Fax

Practice location:
  • Phone: 956-632-6020
  • Fax: 956-630-6643
Mailing address:
  • Phone: 956-632-6020
  • Fax: 965-630-6643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number229533
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: