Healthcare Provider Details

I. General information

NPI: 1992110498
Provider Name (Legal Business Name): JACOB MATTHEW MILLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 N DAKOTA AVE
AMES IA
50014-9019
US

IV. Provider business mailing address

1316 S MAIN ST
CLARION IA
50525-2019
US

V. Phone/Fax

Practice location:
  • Phone: 515-532-2811
  • Fax: 515-532-9336
Mailing address:
  • Phone: 515-532-2811
  • Fax: 515-532-9336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number43-557316-021
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD142357
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: