Basic Information
Provider Information | |||||||||
NPI: | 1386871895 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARRARD | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3650 J DEWEY GRAY CIR | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309091867 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068639797 | ||||||||
FaxNumber: | 7068607686 | ||||||||
Practice Location | |||||||||
Address1: | 2211 LOMAS BLVD NE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871062719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052723217 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2009 | ||||||||
LastUpdateDate: | 10/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | SA00369 | TX | N |   | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant | 363LA2200X | RN188785 | GA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 61461 | NM | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | 791802 | TX | N |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 1386871895 | 01 |   | NPI | OTHER |