Provider Demographics
NPI:1174550925
Name:BALLESTEROS, JORGE MANUEL (CRNA)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:MANUEL
Last Name:BALLESTEROS
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 1:3714 S SUMMERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6902
Mailing Address - Country:US
Mailing Address - Phone:812-240-0977
Mailing Address - Fax:
Practice Address - Street 1:3714 S SUMMERLIN AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6902
Practice Address - Country:US
Practice Address - Phone:812-240-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR56975367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered