Healthcare Provider Details

I. General information

NPI: 1447233325
Provider Name (Legal Business Name): JAY A HONOMICHL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 KENYON RD
FORT DODGE IA
50501-5740
US

IV. Provider business mailing address

PO BOX 310117
DES MOINES IA
50331-0001
US

V. Phone/Fax

Practice location:
  • Phone: 515-573-3101
  • Fax: 515-574-6456
Mailing address:
  • Phone: 800-303-7642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100598
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: