Basic Information
| Provider Information | |||||||||
| NPI: | 1992048870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEVILACQUA | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | EMANUEL | ||||||||
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| Credential: | RN, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563564935 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 COOPER PLZ | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2013 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 26NR15502700 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN2297562 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.