Provider Demographics
NPI:1952457939
Name:PERDOMO, RUBEN JESUS (CRNA)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:JESUS
Last Name:PERDOMO
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 1:4901 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5935
Mailing Address - Country:US
Mailing Address - Phone:850-477-7042
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:4901 GRANDE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5935
Practice Address - Country:US
Practice Address - Phone:850-477-7042
Practice Address - Fax:850-474-9060
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2896962367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3834OtherFL BCBS
P00957902OtherMEDICARE RAILROAD
AL592-10270OtherBLUE CROSS BLUE SHIELD
FLARNP2896962OtherFL LICENSE
FLP00242573OtherMEDICARE RAILROAD
FLG3834OtherFL BCBS