Provider Demographics
NPI:1073594461
Name:GLATTFELT, JERRY EDWARD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:EDWARD
Last Name:GLATTFELT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 PARK LN
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-2878
Mailing Address - Country:US
Mailing Address - Phone:707-428-4272
Mailing Address - Fax:
Practice Address - Street 1:100 BODIN CIR
Practice Address - Street 2:60 TH MSGS/SGCSA
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1804
Practice Address - Country:US
Practice Address - Phone:707-423-5370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-232449367500000X
IL209-003657 APN LICEN367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered