Provider Demographics
NPI:1467874057
Name:JACQUEZ, ADRIAN ALBERTO (CRNA)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:ALBERTO
Last Name:JACQUEZ
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 1:1409 CROSS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7248
Mailing Address - Country:US
Mailing Address - Phone:915-841-8734
Mailing Address - Fax:
Practice Address - Street 1:4815 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2705
Practice Address - Country:US
Practice Address - Phone:915-544-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX731547367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered