Provider Demographics
NPI:1447233325
Name:HONOMICHL, JAY A (CRNA)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:A
Last Name:HONOMICHL
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 310117
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50331-0001
Mailing Address - Country:US
Mailing Address - Phone:800-303-7642
Mailing Address - Fax:
Practice Address - Street 1:802 KENYON RD
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5740
Practice Address - Country:US
Practice Address - Phone:515-573-3101
Practice Address - Fax:515-574-6456
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA100598367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0484121Medicaid
IAI16734Medicare PIN