Provider Demographics
NPI:1003426701
Name:LUFKIN, JESS (CRNA)
Entity Type:Individual
Prefix:
First Name:JESS
Middle Name:
Last Name:LUFKIN
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 1:1891 KINGHORN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4996
Mailing Address - Country:US
Mailing Address - Phone:208-821-5563
Mailing Address - Fax:
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-716-7215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9493739163W00000X, 163WS0200X
INRN9493739163W00000X
ID69208367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No163WS0200XNursing Service ProvidersRegistered NurseSchool