Basic Information
Provider Information
NPI: 1992067185
EntityType: 2
ReplacementNPI:  
OrganizationName: J & M ANESTHESIA LLC
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Mailing Information
Address1: 209 S MAIN ST
Address2:  
City: POPLAR BLUFF
State: MO
PostalCode: 639015831
CountryCode: US
TelephoneNumber: 5736865550
FaxNumber:  
Practice Location
Address1: 1301 1ST ST
Address2:  
City: KENNETT
State: MO
PostalCode: 638572525
CountryCode: US
TelephoneNumber: 5736865550
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/13/2012
LastUpdateDate: 06/13/2012
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: RICKETTS
AuthorizedOfficialFirstName: JOHN
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AuthorizedOfficialTitleorPosition: MBR
AuthorizedOfficialTelephone: 5736865550
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: CRNA
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000X MOY193400000X SINGLE SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

No ID Information.


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