1174845374 NPI number — JEREMY JOSEPH LAFAVE CRNA

Table of content: JEREMY JOSEPH LAFAVE CRNA (NPI 1174845374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174845374 NPI number — JEREMY JOSEPH LAFAVE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAFAVE
Provider First Name:
JEREMY
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174845374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 W MAGNETIC ST
Provider Second Line Business Mailing Address:
ANESTHESIA DEPARTMENT
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855-2711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-225-3595
Provider Business Mailing Address Fax Number:
906-225-3697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 W MAGNETIC ST
Provider Second Line Business Practice Location Address:
ANESTHESIA DEPARTMENT
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-225-3595
Provider Business Practice Location Address Fax Number:
906-225-3697
Provider Enumeration Date:
02/16/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  4704259319 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)