Healthcare Provider Details

I. General information

NPI: 1093060170
Provider Name (Legal Business Name): JEREMY R TAYSOM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 ARROWHEAD DR
EVANSTON WY
82930-9266
US

IV. Provider business mailing address

444 CRANE AVE
EVANSTON WY
82930-4916
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-3636
  • Fax:
Mailing address:
  • Phone: 208-421-4819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-837
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number56824
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: