Provider Demographics
NPI:1699740621
Name:JACOBS, KEVIN WAYNE (CRNA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WAYNE
Last Name:JACOBS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67117-0388
Mailing Address - Country:US
Mailing Address - Phone:316-281-3700
Mailing Address - Fax:316-282-4322
Practice Address - Street 1:720 WEST CENTRAL
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042
Practice Address - Country:US
Practice Address - Phone:316-321-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55098367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered