Provider Demographics
NPI:1902846173
Name:PATES-SWART, JACKOLIN BETH (CRNA)
Entity Type:Individual
Prefix:
First Name:JACKOLIN
Middle Name:BETH
Last Name:PATES-SWART
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WATER HAZARD DR SE
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-7357
Mailing Address - Country:US
Mailing Address - Phone:316-641-5594
Mailing Address - Fax:575-544-7361
Practice Address - Street 1:900 W ASH ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4000
Practice Address - Country:US
Practice Address - Phone:575-544-7361
Practice Address - Fax:575-544-7221
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR44842367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100247710EMedicaid
NM89179510Medicaid
AZ987951Medicaid
NM345515901Medicare PIN
AZ987951Medicaid
AZ8EC369Medicare PIN
NM89179510Medicaid