Provider Demographics
NPI:1174845374
Name:LAFAVE, JEREMY JOSEPH (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JOSEPH
Last Name:LAFAVE
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 1:420 W MAGNETIC ST
Mailing Address - Street 2:ANESTHESIA DEPARTMENT
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2711
Mailing Address - Country:US
Mailing Address - Phone:906-225-3595
Mailing Address - Fax:906-225-3697
Practice Address - Street 1:420 W MAGNETIC ST
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2711
Practice Address - Country:US
Practice Address - Phone:906-225-3595
Practice Address - Fax:906-225-3697
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704259319367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered