Provider Demographics
NPI:1114952926
Name:UNDERWOOD, JASON CRAIG
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:CRAIG
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:CRAIG
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:670 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-2284
Mailing Address - Country:US
Mailing Address - Phone:928-348-9740
Mailing Address - Fax:
Practice Address - Street 1:1600 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4011
Practice Address - Country:US
Practice Address - Phone:928-348-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0390367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ096768Medicaid