Provider Demographics
NPI:1790701589
Name:DE GORTARI, JENNIFER B (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:B
Last Name:DE GORTARI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:BOSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3531 S LOGAN ST
Mailing Address - Street 2:UNIT D408
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3700
Mailing Address - Country:US
Mailing Address - Phone:303-788-6749
Mailing Address - Fax:
Practice Address - Street 1:501 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2702
Practice Address - Country:US
Practice Address - Phone:303-788-6749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO118813367500000X
COCRA-4885367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO56370326Medicaid
CO56370326Medicaid