Individual
BILLY JACK PREMO
Active
Individual
BILLY JACK PREMO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRNA
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R0025846
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100781950A
—
OK
01
—
430001523
MEDICARE PIN
OK
01
—
731189454001
BCBS
OK
Enumeration date
07/25/2006
Last updated
03/12/2015
Update your record
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