Individual
MR. JACK COLT BLAINE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
6709 ACADEMY RD NE STE A, ALBUQUERQUE, NM 87109-3363
(505) 312-4712
Mailing address
36720 PALM CT, RANCHO MIRAGE, CA 92270-2206
(619) 994-2941
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
AP108435
TX
367500000X
Certified Registered Nurse Anesthetist
CRNA0061
AZ
367500000X
Certified Registered Nurse Anesthetist
Primary
CRNA00868
NM
367500000X
Certified Registered Nurse Anesthetist
NA1771
CA
Other
Enumeration date
08/11/2005
Last updated
01/19/2022
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