Provider Demographics
NPI:1255002143
Name:JIMENEZ HARO, ALFONSO (CRNA)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:JIMENEZ HARO
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 1:1101 CALLAWAY DR APT 3908
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4790
Mailing Address - Country:US
Mailing Address - Phone:775-340-5798
Mailing Address - Fax:
Practice Address - Street 1:2430 W PIERCE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3597
Practice Address - Country:US
Practice Address - Phone:575-887-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM65511367500000X
FL9567656163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty