Provider Demographics
NPI:1770620262
Name:RICHARD, JASON NILES (CRNA)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:NILES
Last Name:RICHARD
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 1:88 MDG
Mailing Address - Street 2:4881 SUGAR MAPLE DR
Mailing Address - City:WRIGHT-PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:43433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-304-2451
Mailing Address - Fax:
Practice Address - Street 1:88 MDG
Practice Address - Street 2:4881 SUGAR MAPLE DR
Practice Address - City:WRIGHT-PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:43433-5529
Practice Address - Country:US
Practice Address - Phone:937-304-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.359580-COA1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered