Provider Demographics
NPI:1093060170
Name:TAYSOM, JEREMY R (CRNA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:TAYSOM
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 1:444 CRANE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-4916
Mailing Address - Country:US
Mailing Address - Phone:208-421-4819
Mailing Address - Fax:
Practice Address - Street 1:190 ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9266
Practice Address - Country:US
Practice Address - Phone:307-789-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-837367500000X
WY56824367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered