Provider Demographics
NPI:1003007329
Name:JAUTZ, SHIRLEY A (CRNA)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:A
Last Name:JAUTZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5983 US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:MO
Mailing Address - Zip Code:65789-9538
Mailing Address - Country:US
Mailing Address - Phone:573-686-5550
Mailing Address - Fax:573-686-2139
Practice Address - Street 1:221 PHYSICIANS PARK
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-727-9080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129615367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO917851503Medicaid
MO818074008Medicare PIN