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General NPI Number Information
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NPI Number | 1407152358
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Entity Type | Individual
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Provider Name | JACK B WATERS CRNA
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Gender | Male
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Dates
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Enumeration Date | 02/09/2011
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Last Update Date | 12/20/2021
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Provider Practice Location Address
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Address Line | 2365 E SEGOVIA DR
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City | SAINT GEORGE
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State | UT
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Zip | 84790-7487
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Country | US
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Telephone | 435-773-5585
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Fax |
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Provider Business Mailing Address
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Address Line | 2365 E SEGOVIA DR
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City | SAINT GEORGE
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State | UT
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Zip | 84790-7487
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Country | US
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Telephone | 435-773-5585
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 201160004CRNA
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License Number State | OR
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