Provider Demographics
NPI:1275852378
Name:TEAGUE, JEROMY EUGENE (CRNA)
Entity Type:Individual
Prefix:
First Name:JEROMY
Middle Name:EUGENE
Last Name:TEAGUE
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 1:1630 JASMINE LN
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8446
Mailing Address - Country:US
Mailing Address - Phone:501-908-5249
Mailing Address - Fax:
Practice Address - Street 1:4 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-4510
Practice Address - Country:US
Practice Address - Phone:501-977-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCTP-000137367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered