Healthcare Provider Details

I. General information

NPI: 1003007329
Provider Name (Legal Business Name): SHIRLEY A JAUTZ CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 PHYSICIANS PARK
POPLAR BLUFF MO
63901-3956
US

IV. Provider business mailing address

5983 US HIGHWAY 63
POMONA MO
65789-9538
US

V. Phone/Fax

Practice location:
  • Phone: 573-727-9080
  • Fax:
Mailing address:
  • Phone: 573-686-5550
  • Fax: 573-686-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number129615
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: