Provider Demographics
NPI:1639890775
Name:PREBOLA, JARROD (CRNA)
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:
Last Name:PREBOLA
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 1:6709 ACADEMY RD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3363
Mailing Address - Country:US
Mailing Address - Phone:814-207-3903
Mailing Address - Fax:
Practice Address - Street 1:553 HILLSIDE VIEW DR
Practice Address - Street 2:
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635-7459
Practice Address - Country:US
Practice Address - Phone:814-207-3903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM69004367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered