Provider Demographics
NPI:1588799241
Name:JEFFERSON, LESTER LEE JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:LESTER
Middle Name:LEE
Last Name:JEFFERSON
Suffix:JR
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 1:1718 SW MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2045
Mailing Address - Country:US
Mailing Address - Phone:772-871-9161
Mailing Address - Fax:
Practice Address - Street 1:1718 SW MOCKINGBIRD DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2045
Practice Address - Country:US
Practice Address - Phone:772-871-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2971342367500000X
TX577707367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3044688-00Medicaid