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NPI Code Detail

MEDICARE: LORAN C JACOBS JR. CRNA

MEDICARE: LORAN C JACOBS JR. CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse Anesthetist4704149628MI
2367500000XCertified Registered Nurse AnesthetistRN151239AZ
3367500000XCertified Registered Nurse AnesthetistCRNA0562AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
24704149628OTHERMILICENSE NUMBER

General Provider Information

NPI Number : 1144277575
Entity Type Code : Individual
Provider Name (Legal Business Name) : LORAN C JACOBS JR. CRNA
Provider Business Mailing Address
First Line : 5281 N 99TH AVE
Second Line : STE 100
City : GLENDALE
State : AZ
Zip : 85305-2209
Country : US
Telephone Number : 623-241-6160
Fax Number : 623-691-8502
Provider Business Practice Location Address
First Line : 807 S PONDEROSA ST
Second Line :
City : PAYSON
State : AZ
Zip : 85541-5542
Country : US
Telephone Number : 602-273-6770
Fax Number : 602-889-0483
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/30/2006
Last Update Date : 04/27/2017

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