Provider Demographics
NPI:1104838234
Name:STOUT, JACK (CRNA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:STOUT
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:PO BOX 1672
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78296-1672
Mailing Address - Country:US
Mailing Address - Phone:956-632-6020
Mailing Address - Fax:965-630-6643
Practice Address - Street 1:222 E RIDGE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1251
Practice Address - Country:US
Practice Address - Phone:956-632-6020
Practice Address - Fax:956-630-6643
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX229533367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
8B6148Medicare ID - Type Unspecified