Healthcare Provider Details

I. General information

NPI: 1093415663
Provider Name (Legal Business Name): RHETT JORGENSEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 NORTH 11TH STREET
RICHMOND VA
23298
US

IV. Provider business mailing address

10010 PALACE CT APT A
HENRICO VA
23238-5676
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9000
  • Fax:
Mailing address:
  • Phone: 435-760-7689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024192351
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001314754
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: