Provider Demographics
NPI:1487904298
Name:HADLOCK, JERRY ANTONY (CRNA)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ANTONY
Last Name:HADLOCK
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 1:684 E 320 S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-8532
Mailing Address - Country:US
Mailing Address - Phone:801-615-3292
Mailing Address - Fax:
Practice Address - Street 1:684 E 320 S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-8532
Practice Address - Country:US
Practice Address - Phone:801-615-3292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7091442-8900367500000X
UT7091442-4405367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered