Provider Demographics
NPI:1376840736
Name:BURTON-VIGIL, JESSICA ANN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:BURTON-VIGIL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2247 CALLE CACIQUE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4944
Mailing Address - Country:US
Mailing Address - Phone:719-351-6025
Mailing Address - Fax:
Practice Address - Street 1:2247 CALLE CACIQUE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4944
Practice Address - Country:US
Practice Address - Phone:719-351-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0990494-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ601718Medicaid
COP01126137OtherMEDICARE RAILROAD
CO04035054Medicaid
CO16834542Medicaid
UT1376840736Medicaid
NM74659065Medicaid
NMP00971956OtherRR MEDICARE PTAN
AZ601718Medicaid