Provider Demographics
NPI:1811999642
Name:BLAINE, JACK COLT (CRNA)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:COLT
Last Name:BLAINE
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 1:36720 PALM CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2206
Mailing Address - Country:US
Mailing Address - Phone:619-994-2941
Mailing Address - Fax:
Practice Address - Street 1:6709 ACADEMY RD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3363
Practice Address - Country:US
Practice Address - Phone:505-312-4712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0061367500000X
TXAP108435367500000X
CANA1771367500000X
NMCRNA00868367500000X
OKR0057403367500000X
NMR53959367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00858679Medicare PIN
CABA126ZMedicare PIN
CACD4582Medicare PIN
CARN0440288Medicaid
S39279Medicare UPIN
CAP01295197Medicare PIN
CABA126YMedicare PIN
CAZZZ34009ZMedicare PIN
CAZZZ03424ZMedicare PIN