Provider Demographics
NPI:1245838689
Name:PARAOAN, JETT NYMANN DELACRUZ (PHARMD, MBA)
Entity type:Individual
Prefix:DR
First Name:JETT NYMANN
Middle Name:DELACRUZ
Last Name:PARAOAN
Suffix:
Gender:M
Credentials:PHARMD, MBA
Other - Prefix:DR
Other - First Name:JETT
Other - Middle Name:DELACRUZ
Other - Last Name:PARAOAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD, MBA
Mailing Address - Street 1:905 N TUCKER AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7566
Mailing Address - Country:US
Mailing Address - Phone:240-441-2599
Mailing Address - Fax:
Practice Address - Street 1:US-491
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-8742
Practice Address - Country:US
Practice Address - Phone:505-368-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist