Provider Demographics
NPI:1518643675
Name:WILLIAMSON, JACOB RYAN (CRNA)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RYAN
Last Name:WILLIAMSON
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 1:5809 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604-2597
Mailing Address - Country:US
Mailing Address - Phone:409-718-7589
Mailing Address - Fax:
Practice Address - Street 1:1500 SW 10TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-1301
Practice Address - Country:US
Practice Address - Phone:785-273-8224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX875482163W00000X
KS14-161414-031163W00000X
KS43-558146-031367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse