Provider Demographics
NPI:1992110498
Name:MILLER, JACOB MATTHEW (CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MATTHEW
Last Name:MILLER
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 1:1316 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:IA
Mailing Address - Zip Code:50525-2019
Mailing Address - Country:US
Mailing Address - Phone:515-532-2811
Mailing Address - Fax:515-532-9336
Practice Address - Street 1:2405 N DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-9019
Practice Address - Country:US
Practice Address - Phone:515-532-2811
Practice Address - Fax:515-532-9336
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43-557316-021367500000X
IAD142357367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered