Provider Demographics
NPI:1518424902
Name:PRIOLO, JESSE BEN (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:BEN
Last Name:PRIOLO
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 1:901 RUSSELL AVE APT 121
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-393-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001056367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered