Provider Demographics
NPI:1295848224
Name:REID, JEFFERY HODGE SR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:HODGE
Last Name:REID
Suffix:SR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:CO
Mailing Address - Zip Code:80420-0120
Mailing Address - Country:US
Mailing Address - Phone:719-836-0219
Mailing Address - Fax:719-836-0219
Practice Address - Street 1:315 W 15TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-629-6259
Practice Address - Fax:620-629-6655
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1433359042367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSR69540Medicare UPIN
KS144677Medicare ID - Type Unspecified