Provider Demographics
NPI:1255650610
Name:SCHULTZ, JEFFERY R (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:R
Last Name:SCHULTZ
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 1:202 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1943
Mailing Address - Country:US
Mailing Address - Phone:406-345-3345
Mailing Address - Fax:406-345-3347
Practice Address - Street 1:202 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1943
Practice Address - Country:US
Practice Address - Phone:406-345-3345
Practice Address - Fax:406-345-3347
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLANT9242362367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1255650610OtherCHAMPUS (TRICARE - SOUTH REGION)
FL0025769 00Medicaid
FLG00FPOtherBCBS
FLG00FPOtherBCBS