Provider Demographics
NPI:1902901259
Name:DEJESUS, CARLOS (CRNA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:DEJESUS
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 1:14359 CHERRY LAKE DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5185
Mailing Address - Country:US
Mailing Address - Phone:904-292-2042
Mailing Address - Fax:
Practice Address - Street 1:400 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5784
Practice Address - Country:US
Practice Address - Phone:904-824-4990
Practice Address - Fax:904-824-2226
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9175034367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307485400Medicaid
FL307485400Medicaid