Provider Demographics
NPI:1598168148
Name:NGUYEN, JIM THACH (CRNA)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:THACH
Last Name:NGUYEN
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 1:3968 W SAND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-4174
Mailing Address - Country:US
Mailing Address - Phone:801-580-2697
Mailing Address - Fax:
Practice Address - Street 1:2001 ERRECART BLVD
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-8333
Practice Address - Country:US
Practice Address - Phone:775-738-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000172367500000X
NVCRNA000502367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered