Provider Demographics
NPI:1184222812
Name:MUSTAR, JACOB NICHOLAS
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:NICHOLAS
Last Name:MUSTAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7640 MEADOW BROOKE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-4004
Mailing Address - Country:US
Mailing Address - Phone:330-998-4387
Mailing Address - Fax:
Practice Address - Street 1:444 N MAIN ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310-3110
Practice Address - Country:US
Practice Address - Phone:330-762-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH382581163W00000X
OH0020235367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty