Basic Information
| Provider Information | |||||||||
| NPI: | 1174534754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | GILBERT | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 W FOREST AVE | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860011479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287732505 | ||||||||
| FaxNumber: | 9287732504 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 W FOREST AVE | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860011479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287732505 | ||||||||
| FaxNumber: | 9287732504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CRNA0011 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 363242 | 05 | AZ | MEDICAID |