Healthcare Provider Details

I. General information

NPI: 1689628463
Provider Name (Legal Business Name): JANE E. MCDORMAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JOHNSTON WILLIS DR
RICHMOND VA
23235-4730
US

IV. Provider business mailing address

10800 MIDLOTHIAN TPKE SUITE 265
RICHMOND VA
23235-4724
US

V. Phone/Fax

Practice location:
  • Phone: 804-594-2622
  • Fax: 804-594-0915
Mailing address:
  • Phone: 804-594-2622
  • Fax: 804-594-0915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024164269
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: