Provider Demographics
NPI:1649349945
Name:JEFFERIES, DARREN DALE (CRNA)
Entity type:Individual
Prefix:
First Name:DARREN
Middle Name:DALE
Last Name:JEFFERIES
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-577-4200
Practice Address - Fax:317-577-9503
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY529270163W00000X
NY074952367500000X
VA0024169078367500000X
IN28277440A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00530230OtherRAILROAD PTAN
IN300067393Medicaid
IN264431067OtherMEDICARE PTAN
IN095200099OtherMEDICARE PTAN