Provider Demographics
NPI:1225599889
Name:PHEASANT, JEREME (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREME
Middle Name:
Last Name:PHEASANT
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 1:8600 STATE ROUTE 91 STE 250
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7831
Mailing Address - Country:US
Mailing Address - Phone:309-692-5393
Mailing Address - Fax:
Practice Address - Street 1:8600 STATE ROUTE 91 STE 250
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7831
Practice Address - Country:US
Practice Address - Phone:309-692-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-019155367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered