Basic Information
Provider Information | |||||||||
NPI: | 1063513612 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVES | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1209 NW NORTH RIDGE DRIVE | ||||||||
Address2: | SUITE B | ||||||||
City: | BLUE SPRINGS | ||||||||
State: | MO | ||||||||
PostalCode: | 640156320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8169888415 | ||||||||
FaxNumber: | 8163354003 | ||||||||
Practice Location | |||||||||
Address1: | 201 NW R D MIZE RD | ||||||||
Address2: | ANESTHESIA SERVICES OF BLUE SPRINGS/ST. MARY'S MEDICAL | ||||||||
City: | BLUE SPRINGS | ||||||||
State: | MO | ||||||||
PostalCode: | 640142513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8169888415 | ||||||||
FaxNumber: | 8163354003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2006 | ||||||||
LastUpdateDate: | 03/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2004031152 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 911059301 | 05 | MO |   | MEDICAID |