Provider Demographics
NPI:1487680369
Name:DECKER, JACK (CRNA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DECKER
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 1:1447 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4727
Mailing Address - Country:US
Mailing Address - Phone:989-583-6237
Mailing Address - Fax:989-583-6032
Practice Address - Street 1:1447 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4727
Practice Address - Country:US
Practice Address - Phone:989-583-6237
Practice Address - Fax:989-583-6032
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704110453367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM59110010Medicare PIN