Provider Demographics
NPI:1558958371
Name:PATTON, JACK (CRNA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:PATTON
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 1:2000 E LAMAR BLVD STE 430
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-7338
Mailing Address - Country:US
Mailing Address - Phone:239-790-5582
Mailing Address - Fax:
Practice Address - Street 1:746 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1624
Practice Address - Country:US
Practice Address - Phone:570-770-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN641951367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered