Healthcare Provider Details

I. General information

NPI: 1457741167
Provider Name (Legal Business Name): JACOB L. LUFKIN C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 S 5TH ST
MONTPELIER ID
83254-1597
US

IV. Provider business mailing address

123 VALLEY VIEW DR
MONTPELIER ID
83254-1529
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-1630
  • Fax:
Mailing address:
  • Phone: 208-604-5009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28219682A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number57248
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: