Jack Colt Blaine, CRNA
Individual provider Active NPI Certified Registered Nurse Anesthetist · Albuquerque, NM
NPI 1811999642 · NPPES record last updated Jan 19, 2022
Key facts
- NPI
- 1811999642
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Certified Registered Nurse Anesthetist 367500000X
- License
- CRNA00868 (NM)
- Practice address
- 6709 Academy Rd NE Ste a
Albuquerque, NM 87109-3363 - Phone
- (505) 312-4712
- NPI assigned
- Aug 11, 2005
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 3
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Certified Registered Nurse Anesthetist (Crna)
- Education
- Other, 1989
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Yuma Regional Medical Center
Practice addresses (Care Compare)
2400 S Ave a
Yuma, AZ 85364-7127
Phone (928) 344-2000
Hospital & facility affiliations
- Yuma Regional Medical Center
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in CA, AZ
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20060103000855 | CA | Practitioner - Certified Registered Nurse Anesthetist (Crna) | 6800831579 | |
| I20070911000418 | AZ | Practitioner - Certified Registered Nurse Anesthetist (Crna) | 6800831579 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Certified Registered Nurse
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| NA1771 | CA | MD | Certified Registered Nurse Anesthetist |
| CRNA00868 | NM | MD | Certified Registered Nurse Anesthetist |
| AP108435 | TX | MD | Certified Registered Nurse Anesthetist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Yuma Regional Medical Center | Current |
Accepting new patients | |
| Hendrick Anesthesia Network | Past | Accepting new patients | |
| Jackson County Memorial Hospital Authority | Past | Accepting new patients |
Locations
2400 S Avenue A
Yuma, AZ 85364
Phone (928) 336-7100
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Certified Registered Nurse Anesthetist | 367500000X | CRNA0061 | AZ | |
| Certified Registered Nurse Anesthetist | 367500000X | AP108435 | TX | |
| Certified Registered Nurse Anesthetist | 367500000X | NA1771 | CA | |
| Certified Registered Nurse Anesthetist | 367500000X | CRNA00868 | NM | Yes |
Addresses
Primary practice location
6709 Academy Rd NE Ste a
Albuquerque, NM 87109-3363
Mailing address
36720 Palm CT
Rancho Mirage, CA 92270-2206
Phone (619) 994-2941
Other providers in Albuquerque, NM
- Robin L Blackwell
- Sarah Blackwell
- Scott L Blackwell
- Daniel Kyle Blackwood
- Jimmy Burt Blagg
- Lyndel Blaine
- Savannah Nevaeh Blair Perea
- Susan Gay Blair-Buckley
- Emily Blair
- Michael Ray Blair
All providers in Albuquerque, NM · Certified Registered Nurse Anesthetist in New Mexico
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 19, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.