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NPI Code Detail

MEDICARE: JACOB D BOSTON CRNA

MEDICARE: JACOB D BOSTON 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
1163W00000XRegistered Nurse149114KS
2367500000XCertified Registered Nurse AnesthetistAP61201940WA

General Provider Information

NPI Number : 1558035527
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB D BOSTON CRNA
Provider Business Mailing Address
First Line : 324 N EMPORIA AVE APT 611
Second Line :
City : WICHITA
State : KS
Zip : 67202-2554
Country : US
Telephone Number : 503-516-8419
Fax Number :
Provider Business Practice Location Address
First Line : 1615 DELAWARE ST
Second Line :
City : LONGVIEW
State : WA
Zip : 98632-2367
Country : US
Telephone Number : 360-414-2000
Fax Number : 360-414-7638
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/04/2021
Last Update Date : 03/19/2026

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Directions to “ JACOB D BOSTON CRNA” Practice Location

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