Healthcare Provider Details

I. General information

NPI: 1265554844
Provider Name (Legal Business Name): JARED W OLLERTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 RIVER PARK DR STE 125
PROVO UT
84604-5787
US

IV. Provider business mailing address

PO BOX 1727
PROVO UT
84603-1727
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-8049
  • Fax: 801-374-9195
Mailing address:
  • Phone: 801-375-8049
  • Fax: 801-374-9195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number353604-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: