Healthcare Provider Details

I. General information

NPI: 1790079911
Provider Name (Legal Business Name): JAB LOCUM ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 W 15TH AVE SUITE A
EMPORIA KS
66801-5672
US

IV. Provider business mailing address

PO BOX 388
NEWTON KS
67114-0388
US

V. Phone/Fax

Practice location:
  • Phone: 620-343-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEFFRY BERRY
Title or Position: CRNA
Credential:
Phone: 316-281-3700