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General NPI Number Information
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NPI Number | 1811999642
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Entity Type | Individual
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Provider Name | JACK COLT BLAINE CRNA
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Gender | Male
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 01/19/2022
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Provider Practice Location Address
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Address Line | 6709 ACADEMY RD NE STE A
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-3363
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Country | US
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Telephone | 505-312-4712
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Fax |
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Provider Business Mailing Address
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Address Line | 36720 PALM CT
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-2206
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Country | US
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Telephone | 619-994-2941
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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 | CRNA0061
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | AP108435
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | NA1771
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | CRNA00868
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License Number State | NM
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