Basic Information
| Provider Information | |||||||||
| NPI: | 1003007329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAUTZ | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5983 US HIGHWAY 63 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657899538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
| FaxNumber: | 5736862139 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 PHYSICIANS PARK | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737279080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 04/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 129615 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 917851503 | 05 | MO | MEDICAID |