=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700254331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB A. KAPPLAN NURSE ANESTHESIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2015
-----------------------------------------------------
Last Update Date | 09/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 CEDAR ST # ST3
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-972-2797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 MALL RD
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01805-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-744-5808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 089214
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 089214
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | RN2353222
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------