Provider Demographics
NPI:1518999853
Name:GROSSHEIM, JANA (CRNA)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:
Last Name:GROSSHEIM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E 20TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9039
Mailing Address - Country:US
Mailing Address - Phone:505-326-6400
Mailing Address - Fax:505-326-4606
Practice Address - Street 1:2300 E 30TH ST BLDG A
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8991
Practice Address - Country:US
Practice Address - Phone:505-326-6400
Practice Address - Fax:505-326-4606
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54968367500000X
MO144782367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP00753281OtherRR MEDICARE
AZ444549Medicaid
MO915256317Medicaid
NM26379562Medicaid
UT1518999853Medicaid
CO68527578Medicaid
NMNM302136Medicare PIN