Provider Demographics
NPI:1093888760
Name:DUTCHER, JACOB J (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:DUTCHER
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 1:427 GUY PARK AVE
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-1064
Mailing Address - Country:US
Mailing Address - Phone:518-770-7518
Mailing Address - Fax:518-770-7570
Practice Address - Street 1:427 GUY PARK AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1064
Practice Address - Country:US
Practice Address - Phone:518-770-7518
Practice Address - Fax:518-770-7570
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY541845-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered