Healthcare Provider Details

I. General information

NPI: 1578721544
Provider Name (Legal Business Name): JACOB L CROSBY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE L CROSBY CRNA

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CHANNING WAY
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

PO BOX 94289, MS 631130
SEATTLE WA
98124-0618
US

V. Phone/Fax

Practice location:
  • Phone: 866-487-0277
  • Fax: 770-701-6674
Mailing address:
  • Phone: 866-487-0277
  • Fax: 770-701-6676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number14-103663-111
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number501146-3102
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number55640
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number268930997
License Number StateWY
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number62128
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: