1336560028 NPI number — JEDIDIAH POLETE CRNA

Table of content: JEDIDIAH POLETE CRNA (NPI 1336560028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336560028 NPI number — JEDIDIAH POLETE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLETE
Provider First Name:
JEDIDIAH
Provider Middle Name:
Provider Name Prefix Text:
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:
1336560028
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1444 PETERMAN DR
Provider Second Line Business Mailing Address:
SUITE B18
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71301-3432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-564-4440
Provider Business Mailing Address Fax Number:
702-558-1522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
129 W LAKE MEAD PKWY
Provider Second Line Business Practice Location Address:
SUITE B18
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89015-6954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-564-4440
Provider Business Practice Location Address Fax Number:
702-558-1522
Provider Enumeration Date:
12/23/2013

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:  AP09081 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103246600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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