Provider Demographics
NPI:1992047039
Name:HARTIG, JACOB IVAN (CRNA)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:IVAN
Last Name:HARTIG
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Gender:M
Credentials:CRNA
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Mailing Address - Street 1:3333 EVERGREEN DR NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9493
Mailing Address - Country:US
Mailing Address - Phone:616-364-4200
Mailing Address - Fax:616-364-7347
Practice Address - Street 1:3333 EVERGREEN DR NE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9493
Practice Address - Country:US
Practice Address - Phone:616-364-4200
Practice Address - Fax:616-364-7347
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2014-07-03
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Provider Licenses
StateLicense IDTaxonomies
MI4704267093367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered