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General NPI Number Information
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NPI Number | 1578520136
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Entity Type | Individual
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Provider Name | JAY P IRONSIDE CRNA
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Gender | Male
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Dates
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Enumeration Date | 04/27/2006
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Last Update Date | 05/23/2013
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Provider Practice Location Address
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Address Line | 80 1ST ST
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City | PRAIRIE DU SAC
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State | WI
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Zip | 53578-1550
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Country | US
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Telephone | 608-643-7299
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Fax |
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Provider Business Mailing Address
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Address Line | W14145 CREST VIEW DR
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City | PRAIRIE DU SAC
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State | WI
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Zip | 53578-9559
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Country | US
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Telephone | 608-370-6282
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 147652
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License Number State | WI
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