1073594461 NPI number — MR. JERRY EDWARD GLATTFELT CRNA

Table of content: MR. JERRY EDWARD GLATTFELT CRNA (NPI 1073594461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073594461 NPI number — MR. JERRY EDWARD GLATTFELT CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLATTFELT
Provider First Name:
JERRY
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073594461
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1131 PARK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUISUN CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94585-2878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-428-4272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BODIN CIR
Provider Second Line Business Practice Location Address:
60 TH MSGS/SGCSA
Provider Business Practice Location Address City Name:
TRAVIS AFB
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94535-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-423-5370
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  041-232449 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 209-003657 APN LICEN , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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