Basic Information
| Provider Information | |||||||||
| NPI: | 1992701403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95429 BARNWELL RD | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320341698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043213533 | ||||||||
| FaxNumber: | 5177877365 | ||||||||
| Practice Location | |||||||||
| Address1: | 95429 BARNWELL RD | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320341698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043213533 | ||||||||
| FaxNumber: | 5177877365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 05/16/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 9271732 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0184901 | 05 | OH | MEDICAID | 000000024026 | 01 | OH | ANTHEM PIN | OTHER | 1215930425 | 01 | OH | GROUP NPI | OTHER | 430036019 | 01 | OH | TRAVELERS | OTHER |