Basic Information
| Provider Information | |||||||||
| NPI: | 1992110498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1316 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CLARION | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505252019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155322811 | ||||||||
| FaxNumber: | 5155329336 | ||||||||
| Practice Location | |||||||||
| Address1: | 1316 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CLARION | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505252019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155322811 | ||||||||
| FaxNumber: | 5155329336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 12/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 43-557316-021 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | D142357 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.