Provider Demographics
NPI:1922078161
Name:GENTRY, JEREMY TODD (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:TODD
Last Name:GENTRY
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75504-0779
Mailing Address - Country:US
Mailing Address - Phone:903-792-8888
Mailing Address - Fax:903-792-8984
Practice Address - Street 1:4500 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2740
Practice Address - Country:US
Practice Address - Phone:903-792-8888
Practice Address - Fax:903-792-8984
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX630036367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered