Provider Demographics
NPI:1649292723
Name:HOPPER, JERRAL G (RN,CRNA)
Entity type:Individual
Prefix:PROF
First Name:JERRAL
Middle Name:G
Last Name:HOPPER
Suffix:
Gender:M
Credentials:RN,CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11123 WONDERLAND TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-3944
Mailing Address - Country:US
Mailing Address - Phone:214-654-0612
Mailing Address - Fax:
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:CRNA
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2017
Practice Address - Country:US
Practice Address - Phone:214-820-2170
Practice Address - Fax:214-820-7977
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX572255367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85329UOtherBCBS
TX1587289-03Medicaid
TX85329UOtherBCBS
TX8D7449Medicare ID - Type Unspecified
8F5170Medicare PIN