Healthcare Provider Details

I. General information

NPI: 1588139448
Provider Name (Legal Business Name): JACOB T PFLUM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

3305 N BALLARD RD STE A
APPLETON WI
54911-9001
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-4101
  • Fax: 920-939-3827
Mailing address:
  • Phone: 920-202-3363
  • Fax: 920-939-3827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number189961-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: