Provider Demographics
NPI:1376873844
Name:IRVING, JACOB R (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:IRVING
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:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-0793
Mailing Address - Country:US
Mailing Address - Phone:509-826-1760
Mailing Address - Fax:509-826-7211
Practice Address - Street 1:810 JASMINE ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9578
Practice Address - Country:US
Practice Address - Phone:509-826-1760
Practice Address - Fax:509-826-7211
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60190539367500000X
WARN60190693367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0247069OtherL&I
WAG8902479Medicare PIN